Infection and inflammation stimulate expansion of a CD74+ Paneth cell subset to regulate disease progression

Paneth cells (PCs), a specialized secretory cell type in the small intestine, are increasingly recognized as having an essential role in host responses to microbiome and environmental stresses. Whether and how commensal and pathogenic microbes modify PC composition to modulate inflammation remain unclear. Using newly developed PC-reporter mice under conventional and gnotobiotic conditions, we determined PC transcriptomic heterogeneity in response to commensal and invasive microbes at single cell level. Infection expands the pool of CD74+ PCs, whose number correlates with auto or allogeneic inflammatory disease progressions in mice. Similar correlation was found in human inflammatory disease tissues. Infection-stimulated cytokines increase production of reactive oxygen species (ROS) and expression of a PC-specific mucosal pentraxin (Mptx2) in activated PCs. A PC-specific ablation of MyD88 reduced CD74+ PC population, thus ameliorating pathogen-induced systemic disease. A similar phenotype was also observed in mice lacking Mptx2. Thus, infection stimulates expansion of a PC subset that influences disease progression.

Two waves of coeliac disease incidence in Sweden: a nationwide population-based cohort study from 1990 to 2015

OBJECTIVES

To assess the incidence of biopsy-verified coeliac disease (CD) in Sweden and examine the incidence of duodenal/jejunal biopsies with normal mucosa over time as a proxy for CD awareness and investigation.

DESIGN

Nationwide population-based cohort study 1990-2015 based on biopsy reports indicating villous atrophy (VA) or normal mucosa in the duodenum/jejunum.

RESULTS

We identified 44 771 individuals (63% females) with a biopsy report specifying VA and 412 279 (62% females) with a biopsy report indicating normal mucosa (without a prior biopsy indicating VA). The median age at diagnosis of CD was 28 years. The mean age-standardised incidence rate during the study period was 19.0 per 100 000 person-years (95% CI 17.3 to 20.8). The incidence reached a peak in 1994 for both sexes and a second higher peak in 2002-2003 for females and in 2006 for males. The lifetime risk of developing CD was 1.8% (2.3% in females and 1.4% in males).Prior to 2015, there was a parallel rise in rates for biopsies showing normal duodenal/jejunal mucosa.

CONCLUSIONS

In Sweden, the incidence of CD increased until 2002-2003 in females and until 2006 in males. Since then, the incidence of CD has declined despite increasing duodenal/jejunal biopsies, suggesting that increased awareness and investigation are unlikely to elevate the incidence of the disease in Sweden. Across a lifetime, 1 in 44 females and 1 in 72 males are expected to be diagnosed with CD in Sweden, indicating a relatively high societal burden of disease.

Phenotypic shift of small intestinal intra-epithelial type 1 innate lymphoid cells in celiac disease is associated with enhanced cytotoxic potential

The small intestinal (SI) epithelium harbors a heterogeneous population of lymphocytes that mediate mucosal damage and repair in celiac disease (CD). The composition and roles of human proximal SI intra-epithelial innate lymphoid cells (ILCs), and their alterations in CD, are not well understood. We report that duodenal intra-epithelial ILCs predominantly consist of natural killer (NK)p44⁺ CD127^- cytotoxic ILC1s and NKp44^- CD127⁺ helper ILC1s, while ILC3s only represent a minor population. In patients with newly diagnosed or active CD (ACD) and refractory CD type 1 (RCD I), the frequency of SI NKp44⁺ ILCs is decreased, with restoration of NKp44⁺ ILC frequency observed in patients adhering to a gluten-free diet who show evidence of mucosal healing. Moreover, the frequency of SI NKp44^- ILCs is increased in ACD and RCD I patients and correlates with the severity of villous atrophy and epithelial damage, as assessed by serum levels of fatty acid binding protein 2 (FABP2). We show that the ILC alterations in CD represent a phenotypic shift of cytotoxic ILC1s rather than an increase in helper ILC1s or transdifferentiation of ILC1s to ILC3s, and activation-induced loss of NKp44 by cytotoxic ILC1s is associated with increased interferon (IFN)-γ expression and release of lytic granules. These findings suggest that intra-epithelial NKp44^- CD127^- cytotoxic ILC1s may contribute to mucosal damage in CD.

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.

Persistent mucosal damage and risk of epilepsy in people with celiac disease

BACKGROUND AND PURPOSE

Celiac disease (CD) is associated with an increased risk of developing epilepsy, a risk that persists after CD diagnosis. A significant proportion of patients with CD have persistent villous atrophy (VA) on follow-up biopsy. The objective of this study was to determine whether persistent VA on follow-up biopsy affected long-term epilepsy risk and epilepsy-related hospital emergency admissions.

METHODS

This was a nationwide cohort study. We identified all people in Sweden with histological evidence of CD who underwent a follow-up small intestinal biopsy (1969-2008). We compared those with persistent VA with those who showed histological improvement, assessing the development of epilepsy and related emergency hospital admissions (defined according to relevant International Classification of Diseases codes in the Swedish Patient Register). Cox regression analysis was used to assess outcome measures.

RESULTS

Villous atrophy was present in 43% of 7590 people with CD who had a follow-up biopsy. The presence of persistent VA was significantly associated with a reduced risk of developing newly-diagnosed epilepsy (hazard ratio, 0.61; 95% confidence interval, 0.38-0.98). On stratified analysis, this effect was primarily amongst males (hazard ratio, 0.35; 95% confidence interval, 0.15-0.80). Among the 58 patients with CD with a prior diagnosis of epilepsy, those with persistent VA were less likely to visit an emergency department with epilepsy (hazard ratio, 0.37; 95% confidence interval, 0.09-1.09).

CONCLUSIONS

In a population-based study of individuals with CD, persisting VA on follow-up biopsy was associated with reduced future risk of developing epilepsy but did not influence emergency epilepsy-related hospital admissions. The mechanism as to why persistent VA confers this benefit requires further exploration.

Commercially available glutenases: a potential hazard in coeliac disease

BACKGROUND

The only treatment for celiac disease (CD) is a gluten-free diet (GFD). However, there is interest among patients in a medical therapy to replace or help with a GFD. Therapies include gluten-degrading enzymes (glutenases). There are glutenases available marketed as dietary supplements that have not been demonstrated to digest the toxic epitopes of gluten.

METHODS

We investigated the contents, claims, and disclaimers of glutenase products and assessed patient interest using Google AdWords to obtain Google search frequencies.

RESULTS

Among 14 glutenase product, all contained proteases, eight contained X-prolyl exopeptidase dipeptidyl peptidase IV, two did not state the protease contents, and eight failed to specify the name or origin of all proteases. Eleven contained carbohydrases and lipases and three probiotics. One declared wheat and milk as allergens, two contained herbal products (type not stated) and one Carica papaya. Thirteen claimed to degrade immunogenic gluten fragments, four claimed to help alleviate gastrointestinal symptoms associated with eating gluten. Disclaimers included not being evaluated by the US Food and Drug Administration and products not intended to diagnose, treat, cure, or prevent any disease. On Google AdWords, the search frequency for the product names and the search terms was 3173 searches per month.

CONCLUSIONS

The names of these products make implicit claims that appear to be supported by the claims on the labels and websites for which there is no scientific basis. Google search data suggest great interest and therefore possible use by patients with CD. There needs to be greater oversight of these 'drugs'.

Outcome of breath tests in adult patients with suspected small intestinal bacterial overgrowth

AIM

The aim was to investigate breath test outcomes in patients with suspected SIBO and indicative symptoms of SIBO, diagnosed by breath testing.

BACKGROUND

Breath testing is used to detect small intestinal bacterial overgrowth (SIBO) by measuring hydrogen and methane produced by intestinal bacteria.

METHODS

This retrospective cross sectional study included 311 patients with gastrointestinal symptoms who underwent the breath test for evaluation of SIBO at Celiac Disease Center at Columbia University, New York, in 2014-2015. The patients were divided into two groups based on the physician's choice: lactulose breath test group (72%) and glucose breath test group (28%). Among them, 38% had a history of celiac disease or non-celiac gluten sensitivity.

RESULTS

In total, 46% had a positive breath test: 18% were positive for methane, 24 % positive for hydrogen and 4% positive for both gases (p=0.014). Also, 50% had a positive lactulose breath result and 37% had a positive glucose breath result (p=0.036). The most common symptom for performing the breath test was bloating and the only clinical symptom that significantly showed a positive glucose breath test was increased gas (p=0.028).

CONCLUSION

Lactulose breath test was more often positive than glucose breath test. Positivity for hydrogen was more common than methane. Bloating was the most frequently perceived symptom of the patients undergoing the breath test but the only statistically significant clinical symptom for a positive glucose breath test was increased gas. Furthermore, the results showed that there was no significant association between positive breath test result and gender, age, non-celiac gluten sensitivity or celiac disease.

Ethnic Variations in Duodenal Villous Atrophy Consistent With Celiac Disease in the United States

BACKGROUND & AIMS

Celiac disease is a common disorder with a worldwide distribution, although the prevalence among different ethnicities varies. We aimed to measure the prevalence of duodenal villous atrophy among patients of different ethnicities throughout the United States.

METHODS

We performed a cross-sectional study of all patients who had duodenal biopsies submitted to a national pathology laboratory between January 2, 2008 and April 30, 2015. The prevalence of villous atrophy was calculated for the following ethnicities by using a previously published algorithm based on patient names: North Indian, South Indian, East Asian, Hispanic, Middle Eastern, Jewish, and other Americans.

RESULTS

Among all patients (n = 454,885), the median age was 53 years, and 66% were female. The overall prevalence of celiac disease was 1.74%. Compared with other Americans (n = 380,163; celiac disease prevalence, 1.83%), celiac disease prevalence was lower in patients of South Indian (n = 177, 0%; P = .08), East Asian (n = 4700, 0.15%; P ≤ .0001), and Hispanic (n = 31,491, 1.06%; P ≤ .0001) ethnicities. Celiac disease was more common in patients from the Punjab region (n = 617, 3.08%) than in patients from North India (n = 1195, 1.51%; P = .02). The prevalence of celiac disease among patients of Jewish (n = 17,806, 1.80%; P = .78) and Middle Eastern (n = 1903, 1.52%; P = .33) ethnicities was similar to that of other Americans. Among Jewish individuals (n = 17,806), the prevalence of celiac disease was 1.83% in Ashkenazi persons (n = 16,440) and 1.39% in Sephardic persons (n = 1366; P = .24).

CONCLUSIONS

Among patients undergoing duodenal biopsy, individuals from the Punjab region of India constitute the ethnic group in the United States with the highest prevalence of villous atrophy consistent with celiac disease. Compared with other Americans, villous atrophy prevalence on duodenal biopsy is significantly lower among U.S. residents of South Indian, East Asian, and Hispanic ancestry.

The coeliac stomach: gastritis in patients with coeliac disease

BACKGROUND

Lymphocytic gastritis (LG) is an uncommon entity with varying symptoms and endoscopic appearances. This condition, as well as two forms of H. pylori-negative gastritis [chronic active gastritis (CAG) and chronic inactive gastritis (CIG)], appears to be more common in patients with coeliac disease (CD) based on single-centred studies.

AIM

To compare the prevalence of LG, CAG and CIG among those with normal duodenal histology (or nonspecific duodenitis) and those with CD, as defined by villous atrophy (Marsh 3).

METHODS

We analysed all concurrent gastric and duodenal biopsy specimens submitted to a national pathology laboratory during a 6-year period. We performed multiple logistic regression to identify independent predictors of each gastritis subtype.

RESULTS

Among patients who underwent concurrent gastric and duodenal biopsy (n = 287,503), the mean age was 52 and the majority (67%) were female. Compared to patients with normal duodenal histology, LG was more common in partial villous atrophy (OR: 37.66; 95% CI: 30.16-47.03), and subtotal/total villous atrophy (OR: 78.57; 95% CI: 65.37-94.44). CD was also more common in CAG (OR for partial villous atrophy 1.93; 95% CI: 1.49-2.51, OR for subtotal/total villous atrophy 2.42; 95% CI: 1.90-3.09) and was similarly associated with CIG (OR for partial villous atrophy 2.04; 95% CI: 1.76-2.35, OR for subtotal/total villous atrophy 2.96; 95% CI: 2.60-3.38).

CONCLUSIONS

Lymphocytic gastritis is strongly associated with coeliac disease, with increasing prevalence correlating with more advanced villous atrophy. Chronic active gastritis and chronic inactive gastritis are also significantly associated with coeliac disease. Future research should measure the natural history of these conditions after treatment with a gluten-free diet.

Mucosal healing in patients with celiac disease and outcomes of pregnancy: a nationwide population-based study

BACKGROUND & AIMS

Studies have associated undiagnosed celiac disease with adverse outcomes of pregnancy. We investigated the association between persistent villous atrophy and outcomes of pregnancy in women with celiac disease.

METHODS

We collected data on 337 women with celiac disease who gave birth (to 460 infants) within 5 years of a follow-up biopsy, from 28 pathology departments in Sweden. We compared birth outcomes from women whose follow-up biopsy showed persistent villous atrophy (Marsh score, 3; n = 142; 31% of study population) with those of women with mucosal recovery (n = 318; 69%). We used multivariable logistic regression (adjusted for maternal age, parity, country of birth, smoking, infant sex, and calendar year of birth) to evaluate the association between persistent villous atrophy and pregnancy outcomes.

RESULTS

Intrauterine growth restriction occurred during 3.5% of pregnancies in women with persistent villous atrophy vs 3.8% of those with mucosal healing (adjusted odds ratio [OR], 0.61; 95% confidence interval [CI], 0.19-1.99). There was no significant association between persistent villous atrophy and low birth weight (OR, 0.98; 95% CI, 0.41-2.39), preterm birth (OR, 1.66; 95% CI, 0.72-3.83), or cesarean section (OR, 0.86; 95% CI, 0.51-1.46).

CONCLUSIONS

Although undiagnosed celiac disease has been associated with adverse outcomes of pregnancy, we found no evidence from a nationwide population-based study that persistent villous atrophy, based on analysis of follow-up biopsies, increases risk compared with mucosal healing.

Predictors of persistent villous atrophy in coeliac disease: a population-based study

BACKGROUND

Villous atrophy (VA) with intraepithelial lymphocytosis is the histological hallmark of coeliac disease (CD), but reported rates of mucosal recovery are variable.

AIM

To determine the impact of age and other demographic variables on the probability of persistent VA on follow-up biopsy.

METHODS

We identified patients with VA on duodenal histology at all 28 Swedish pathology departments during the years spanning 1969-2008. We examined age, gender, calendar period, duration of disease and educational attainment to determine predictors of persistent VA.

RESULTS

Of 7648 patients with CD who underwent follow-up biopsy, persistent VA was present in 3317 (43%; 95% CI 42-44%). The effect of age on persistent VA varied according to time period; among those biopsied in the years spanning 2000-2008, the prevalence of persistent VA was 31%, and increasing age was associated with increasing rates of persistent VA (17% among those younger than 2 years compared to 56% among those ≥70 years). In contrast, persistent VA did not vary widely by age in earlier years. On multivariate analysis (restricted to the calendar period 2000-2008, 2-5 years after CD diagnosis), persistent VA was more common among males (OR 1.43; 95% CI 1.07-1.90) and less common among patients with higher educational attainment (OR for college degree vs. <2 years of high school 0.52, 95% CI 0.35-0.78).

CONCLUSIONS

The prevalence of persistent villous atrophy has changed over time, with greater rates of healing in recent years. Social differences in persistent villous atrophy suggest that access and/or education regarding the gluten-free diet impact mucosal healing.

Prior endoscopy in patients with newly diagnosed celiac disease: a missed opportunity?

BACKGROUND

Celiac disease (CD) is under-diagnosed in the United States, and factors related to the performance of endoscopy may be contributory.

AIM

To identify newly diagnosed patients with CD who had undergone a prior esophagogastroduodenoscopy (EGD) and examine factors contributing to the missed diagnosis.

METHODS

We identified all patients age ≥ 18 years whose diagnosis of CD was made by endoscopy with biopsy at our institution (n = 316), and searched the medical record for a prior EGD. We compared those patients with a prior EGD to those with without a prior EGD with regard to age at diagnosis and gender, and enumerated the indications for EGD.

RESULTS

Of the 316 patients diagnosed by EGD with biopsy at our center, 17 (5 %) had previously undergone EGD. During the prior non-diagnostic EGD, a duodenal biopsy was not performed in 59 % of the patients, and ≥ 4 specimens (the recommended number) were submitted in only 29 % of the patients. On the diagnostic EGD, ≥ 4 specimens were submitted in 94 %. The mean age of diagnosis of those with missed/incident CD was 53.1 years, slightly older than those diagnosed with CD on their first EGD (46.8 years, p = 0.11). Both groups were predominantly female (missed/incident CD: 65 vs. 66 %, p = 0.94).

CONCLUSIONS

Among 17 CD patients who had previously undergone a non-diagnostic EGD, non-performance of duodenal biopsy during the prior EGD was the dominant feature. Routine performance of duodenal biopsy during EGD for the indications of dyspepsia and reflux may improve CD diagnosis rates.

Mucosal healing and mortality in coeliac disease

BACKGROUND

Coeliac disease (CD), characterised by the presence of villous atrophy (VA) in the small intestine, is associated with increased mortality, but it is unknown if mortality is influenced by mucosal recovery.

AIMS

To determine whether persistent VA is associated with mortality in CD.

METHODS

Through biopsy reports from all pathology departments (n = 28) in Sweden, we identified 7648 individuals with CD (defined as VA) who had undergone a follow-up biopsy within 5 years following diagnosis. We used Cox regression to examine mortality according to follow-up biopsy.

RESULTS

The mean age of CD diagnosis was 28.4; 63% were female; and the median follow-up after diagnosis was 11.5 years. The overall mortality rate of patients who underwent follow-up biopsy was lower than that of those who did not undergo follow-up biopsy (Hazard Ratio 0.88, 95% CI: 0.80-0.96). Of the 7648 patients who underwent follow-up biopsy, persistent VA was present in 3317 (43%). There were 606 (8%) deaths. Patients with persistent VA were not at increased risk of death compared with those with mucosal healing (HR: 1.01; 95% CI: 0.86-1.19). Mortality was not increased in children with persistent VA (HR: 1.09 95% CI: 0.37-3.16) or adults (HR 1.00 95% CI: 0.85-1.18), including adults older than age 50 years (HR: 0.96 95% CI: 0.80-1.14).

CONCLUSIONS

Persistent villous atrophy is not associated with increased mortality in coeliac disease. While a follow-up biopsy will allow detection of refractory disease in symptomatic patients, in the select population of patients who undergo repeat biopsy, persistent villous atrophy is not useful in predicting future mortality.

Season of birth in a nationwide cohort of coeliac disease patients

BACKGROUND AND OBJECTIVE

Genetic factors alone cannot explain the risk of developing coeliac disease (CD). Children born in summer months are likely to be weaned and introduced to gluten during winter when viral infections are more frequent. Earlier studies on birth season and CD are limited in sample size and results are contradictory.

METHOD

Case-control study. We used biopsy reports from all 28 Swedish pathology departments to identify individuals with CD, defined as small intestinal villous atrophy (n=29 096). The government agency Statistics Sweden then identified 144 522 controls matched for gender, age, calendar year and county. Through conditional logistic regression we examined the association between summer birth (March-August) and later CD diagnosis (outcome measure).

RESULTS

Some 54.10% of individuals with CD versus 52.75% of controls were born in the summer months. Summer birth was hence associated with a small increased risk of later CD (OR 1.06; 95% CI 1.03 to 1.08; p<0.0001). Stratifying CD patients according to age at diagnosis, we found the highest OR in those diagnosed before age 2 years (OR 1.17; 95% CI 1.10 to 1.26), while summer birth was not associated with a CD diagnosis in later childhood (age 2-18 years: OR 1.02; 95% CI 0.97 to 1.08), but had a marginal effect on the risk of CD in adulthood (age ≥18 years: OR 1.04; 95% CI 1.01 to 1.07).

CONCLUSIONS

In this study, summer birth was associated with an increased risk of later CD, but the excess risk was small, and general infectious disease exposure early in life is unlikely to be a major cause of CD.

The Oslo definitions for coeliac disease and related terms

OBJECTIVE

The literature suggests a lack of consensus on the use of terms related to coeliac disease (CD) and gluten.

DESIGN

A multidisciplinary task force of 16 physicians from seven countries used the electronic database PubMed to review the literature for CD-related terms up to January 2011. Teams of physicians then suggested a definition for each term, followed by feedback of these definitions through a web survey on definitions, discussions during a meeting in Oslo and phone conferences. In addition to 'CD', the following descriptors of CD were evaluated (in alphabetical order): asymptomatic, atypical, classical, latent, non-classical, overt, paediatric classical, potential, refractory, silent, subclinical, symptomatic, typical, CD serology, CD autoimmunity, genetically at risk of CD, dermatitis herpetiformis, gluten, gluten ataxia, gluten intolerance, gluten sensitivity and gliadin-specific antibodies.

RESULTS

CD was defined as 'a chronic small intestinal immune-mediated enteropathy precipitated by exposure to dietary gluten in genetically predisposed individuals'. Classical CD was defined as 'CD presenting with signs and symptoms of malabsorption. Diarrhoea, steatorrhoea, weight loss or growth failure is required.' 'Gluten-related disorders' is the suggested umbrella term for all diseases triggered by gluten and the term gluten intolerance should not to be used. Other definitions are presented in the paper.

CONCLUSION

This paper presents the Oslo definitions for CD-related terms.

Celiac disease in children: an old disease with new features

Celiac disease is an underdiagnosed condition in children with variable manifestations. Presenting symptoms in children are changing over time, are impacted by age and geography, and are distinct from those of adults with this disease. Prompt diagnosis of celiac disease in affected children may avoid growth and nutritional deficits in addition to preventing long term disease complications such as infertility and malignancy. Diagnosis and management of celiac disease in children requires expert medical and nutritional care to maximize positive outcomes.

Clinical management of coeliac disease

OBJECTIVE

To describe the prevalence of Coeliac disease (CD) and its clinical management.

METHODS

Narrative review.

RESULTS

Coeliac disease (CD) is an immune-mediated disorder that primarily affects the gastrointestinal (GI) tract. Recent data suggest a prevalence of about 1% in most Western countries, a figure that likely represents an increase in the prevalence of CD. Risk groups include those who are members of families with individuals who have CD as well as those with Type I diabetes and a variety of autoimmune diseases. Whereas biopsy is the gold standard in diagnosis, serological tests are crucial in determining who should undergo endoscopy and biopsy. HLA testing should be used only to rule out CD. Currently, a gluten-free diet is the only available therapy.

CONCLUSION

In conclusion, CD is one of the most common immune-mediated disorders in the Western world. It should be considered in patients with a number of varying GI and non-GI symptoms, as well as in high-risk groups that include first-degree relatives.

CCR9-positive lymphocytes and thymus-expressed chemokine distinguish small bowel from colonic Crohn's disease

BACKGROUND & AIMS

Thymus-expressed chemokine (TECK) or CCL25) is selectively expressed in the small bowel (SB), where lamina propria lymphocytes (LPL) and intraepithelial leukocyte expressing the cognate chemokine receptor CCR9 predominate. We characterize the role of TECK and CCR9-expresing lymphocytes in small intestinal Crohn's disease.

METHODS

CCR9 expression on lymphocytes from lamina propria, mesenteric lymph node, and peripheral blood was analyzed by flow cytometry and by Northern blotting for LPL. TECK expression was analyzed in inflamed SB and colon by reverse-transcription polymerase chain reaction and immunohistochemistry.

RESULTS

The fraction of CCR9(+) T cells in inflamed SB was significantly lower than in uninvolved SB mucosa. In contrast, in peripheral blood lymphocytes, CCR9(+) lymphocytes were markedly elevated in patients with small bowel Crohn's or celiac disease, but not in patients with purely colonic Crohn's. Also, TECK expression is altered in inflamed small bowel, being intensely expressed in a patchy distribution in crypt epithelial cells in proximity to lymphocytic infiltrates. TECK is not expressed in either normal or inflamed colon.

CONCLUSIONS

In SB immune-mediated diseases, there is repartitioning of CCR9(+) lymphocytes between SB and blood and an altered pattern of TECK expression in SB Crohn's. The TECK/CCR9 ligand/receptor pair may play an important role in the pathogenesis of SB Crohn's disease.

Macroamylasemia in patients with celiac disease

OBJECTIVE

Macroamylasemia is considered to be rarely associated with celiac disease (CD). We have evaluated patients in whom macroamylasemia or elevated total amylase (TA) led to the diagnosis of CD. These cases served as a catalyst for examining the prevalence of elevated TA and macroamylase (MA) in patients with active CD.

METHOD

Total amylase and MA measurements were performed in the sera of 124 celiac patients with positive antiendomysium and tissue transglutaminase tests, in 100 patients on gluten-free diet (GFD) with negative serology test results, and in the sera of 89 healthy controls. Macroamylasemia was measured by using the PEG precipitation method.

RESULTS

Twenty-three newly diagnosed celiac patients had elevated serum amylase levels (>2 SD above the controls). The average TA and MA levels were significantly elevated in both celiac groups. The nonprecipitated amylase levels (pancreatic and salivary amylase fractions) were not different from those of the controls. Three controls (3.4%), 21 newly diagnosed celiac (16.8%), and seven patients on GFD (7%) had significantly elevated MA activity in their sera.

CONCLUSIONS

A significant percentage of the newly diagnosed patients with CD have macroamylasemia. Serum MA remained elevated in some patients on strict GFD. In addition, in the presence of an elevated amylase or MA the possibility of CD should be considered.

Osteoporosis in a north american adult population with celiac disease

OBJECTIVE

Osteoporosis, common in European and South American adults with celiac disease, has not been reported in those patients with celiac disease residing in North America. We therefore evaluated bone density in a group of patients from the United States.

METHODS

Patients (105 women and 23 men) with celiac disease, who had completed a questionnaire and had bone mineral density (BMD) measured by dual energy x-ray absorptiometry, were evaluated. The patients were an average age of 56 yr old (range 21-83 yr) and had been on a gluten-free diet from 0 months to 46 yr (mean 7.5 yr).

RESULTS

Osteoporosis (T score < -2.5) was present in 34% of the patients at the lumbar spine, 27% at the femoral neck, and 36% at the radius. Low bone mass (T score between -1.0 and -2.5) was present in 38% at the lumbar spine, 44% at the femoral neck, and 32% at the radius. When compared to age-matched controls, men were more severely affected than women. BMD did not differ between those on a gluten-free diet and those who had not begun therapy. BMD was remeasured 16 +/- 2 months after beginning a gluten-free diet in 5 patients; it increased by 7.5% at the femoral neck (p < 0.02). In 16 patients who had followed a gluten-free diet for an average of 12 yr, BMD remained stable over an additional 2 yr of observation.

CONCLUSIONS

Osteoporosis and low bone mass often affect North American adults with celiac disease, whether or not they are on dietary therapy. Routine screening for osteoporosis is indicated in patients with celiac disease.

All that scallops is not celiac disease

BACKGROUND

Scalloping of duodenal folds as well as a mosaic mucosal pattern, decreased folds, and increased vascularity are markers of duodenal mucosal injury, the most common cause being celiac disease. We have recognized scalloping in patients with a variety of conditions other than celiac disease.

METHODS

Clinical, endoscopic and histologic data were reviewed from selected patients with endoscopically visualized scalloped folds along with testing for endomysial antibodies. Biopsy specimens were examined histologically for villous:crypt ratio, intraepithelial lymphocytes, and inflammation.

RESULTS

Thirteen patients with scalloped folds underwent endoscopy for the following reasons: family history of celiac disease and osteoporosis, gastrointestinal bleeding, dyspepsia (2), B(12)/ folate deficiency (4), and diarrhea (8). Histologic examination was abnormal in all but 1 patient. Villous atrophy or flattening as evidenced by reduced villous:crypt ratio was seen in 11 of 13 patients. Other abnormalities were edematous or broadened villi (10), intraepithelial lymphocytosis (7), and infiltration of lamina propria (6). An infectious organism was identified in 6 patients (46%). Celiac disease was excluded by the lack of specific biopsy findings combined with endomysial antibody testing. Final diagnoses were normal (1), eosinophilic enteritis (1), giardiasis (1), tropical sprue (4), human immunodeficiency virus-related diseases (6) including human immunodeficiency virus enteropathy (1).

CONCLUSION

We conclude that scalloping is not specific for celiac disease but rather a predictor of mucosal disease as evidenced by villous atrophy, widening, and edema.

Significance of unsuspected celiac disease detected at endoscopy

BACKGROUND

Endoscopy provides an opportunity to diagnose unsuspected celiac disease.

METHODS

We prospectively identified patients undergoing endoscopy for reasons other than the evaluation of diarrhea or suspected malabsorption, who had endoscopic signs in the duodenum suggestive of celiac disease and in whom villous atrophy was confirmed. Patients were assessed for nutritional deficiencies, reduced bone density, parameters of calcium metabolism, and malignancies.

RESULTS

Nine patients (3 women and 6 men) were identified among 1749 patients undergoing endoscopy between January 1990 and May 1998, representing a rate of unsuspected celiac disease of 1 per 194 endoscopies. The duodenal abnormalities were as follows: reduced or absent folds in 6, scalloped folds in 5, mosaic appearance in 3, and mucosal fissures in 2. Assessment revealed iron deficiency in 5, folate deficiency in 1, osteopenia in 4, osteoporosis in 1, and hypocalciuria in 4. Three had malignancies associated with celiac disease, 2 esophageal squamous carcinomas, and 1 jejunal adenocarcinoma.

CONCLUSIONS

Unsuspected celiac disease can be diagnosed at endoscopy by recognition of changes in the duodenum. When detected, patients have one or more manifestations of the disease. Celiac disease is more common in the United States than previously considered and endoscopy provides an opportunity to establish the diagnosis.

The use of intravenous H2-receptor antagonists in a tertiary care hospital

OBJECTIVE

The rationale for the widespread use of intravenous H2 receptor antagonists(IVH2 RA) in hospitalized patients is not clear. We therefore examined prescribing patterns and, using strict criteria, determined whether use was appropriate. Cost of administration and potential savings were also determined.

METHODS

Data were obtained prospectively on 100 consecutive patients prescribed intravenous ranitidine and retrospectively on patients admitted with gastrointestinal (GI) bleeding.

RESULTS

For the prospective study, various indications for prescribing intravenous ranitidine were given, including postoperative patients and patients treated with steroids. Using criteria from published literature 80% of the use was considered inappropriate. Nearly 40% of the doses were given while the patient was tolerating oral intake. Creatinine clearance was impaired in 26% of patients, though only one had dosage reduction. Estimated annual cost of intravenous ranitidine was $317,000. The retrospective study of 86 consecutive patients admitted with GI bleeding revealed that all patients received intravenous ranitidine on admission, none of which was considered appropriate. The final diagnoses were peptic ulcer (49), colonic process (11), esophagitis (seven), gastric erosions (five), esophageal varices (five), Mallory-Weiss tears (four), duodenitis (two), no diagnosis (three), and jejunal ulcer (one).

CONCLUSIONS

Inappropriate use of intravenous ranitidine is common. This includes inappropriate indication, dosage, and duration of use. Large financial benefits could have been obtained if close attention was given to prescribing patterns.

Iron-rich foci in chronic viral hepatitis

Stainable iron in the liver (hemosiderosis) is most commonly seen in individuals with homozygous genetic hemochromatosis, prior transfusion, hemolysis, porphyria cutanea tarda, and chronic alcohol-induced liver disease. In chronic viral hepatitis, however, significant hepatocellular hemosiderosis is uncommon. This report describes unusual foci of hepatocellular hemosiderosis ("iron-rich foci" or IRF) in liver biopsy specimens from three patients with chronic hepatitis with or without cirrhosis (two hepatitis C-related, one hepatitis B-related). IRF present within the lobular parenchyma or cirrhotic nodules contrasted sharply with the immediately adjacent hemosiderin-negative liver tissue. Serum iron indices were abnormal in all three patients, but homozygous hemochromatosis was ruled out based on the hepatic iron concentration and hepatic iron index for each case. These cases highlight the potential for irregular iron storage in chronic viral liver disease and possible confusion with genetic hemochromatosis. The possible pathogenesis of IRF and the relationship of iron storage to the outcome of interferon therapy in chronic viral hepatitis are discussed.

Combined magnification endoscopy with chromoendoscopy in the evaluation of patients with suspected malabsorption

BACKGROUND

Magnification endoscopy and chromoendoscopy together have been used to evaluate mucosal detail in a number of conditions, including Barrett's esophagus and flat colonic polyps, but they have not been used to evaluate villous atrophy in the proximal small intestine.

METHODS

Thirty-four patients suspected of having a malabsorption syndrome (either celiac disease or tropical sprue) were evaluated using an Olympus magnification gastroscope in both normal and high magnification settings. Indigo carmine dye spraying techniques were used to assist in evaluating duodenal mucosa for evidence of villous atrophy. The accuracy of endoscopically predicted villous atrophy was assessed by histologic evaluation of biopsy specimens taken in the descending duodenum.

RESULTS

Magnification endoscopy with dye spraying was both highly sensitive (94%) and specific (88%) in identifying patients with villous atrophy. This technique was more accurate (91%) in identifying patients with partial atrophy than standard endoscopy (9%, p < 0.01) and was also useful in identifying patients with patchy villous atrophy (5 of 5) to allow directed biopsies of abnormal tissue.

CONCLUSION

Magnification endoscopy with chromoendoscopy is a promising technique for the evaluation of patients with suspected malabsorption. This technique is especially valuable in patients with partial atrophy, where villous abnormalities can be patchy and the duodenum usually appears normal during standard endoscopy.

Increased expression of the cyclin D1 gene in Barrett's esophagus

Previous studies have found a 3-10-fold amplification and overexpression of the cyclin D1 gene in about 32% of human esophageal squamous cell carcinoma. The purpose of this study was to evaluate the prevalence of increased expression of the cyclin D1 protein in Barrett's esophagus. Using 69 formalin-fixed and paraffin-embedded human esophageal specimens, which had been removed endoscopically or obtained at surgery during 1993 and 1994, all immunohistochemical analyses were performed using an avidin-biotin complex immunoperoxidase technique. Increased nuclear expression of the cyclin D1 protein was noted in 32 of 69 samples (46%; 44% of the samples from males and 50% of the samples from females). Positive nuclear staining for the cyclin D1 protein in Barrett's disease with intestinal metaplasia was found in 38% of the male cases and 25% of the female cases, whereas in gastric metaplasia it was positive in 33% of men and 48% of women. Nuclear accumulation of the cyclin D1 protein was also found in both dysplastic and nondysplastic lesions, and it was not associated with sex, age, or cigarette or alcohol consumption. Samples from patients taking proton pump inhibitors tended to be less frequently positive (32%) for cyclin D1 nuclear staining when compared to patients taking H2 antagonists (45%) or antacids (55%). These studies suggest that increased expression of cyclin D1 is an early event in the tumorigenic process of esophageal adenocarcinomas and that the increased expression of this gene might predispose the epithelium to malignant transformation.

Gastric duplication cyst communicating with the pancreatic duct: a rare cause of recurrent abdominal pain

A 41-year-old woman with recurrent attacks of postprandial abdominal pain was found on endoscopic retrograde cholangiopancreatography and subsequent computed tomographic scan to have an enteric duplication within the substance of the pancreas with communication to the pancreatic duct. Celiotomy demonstrated a noncontiguous gastric duplication cyst. Internal drainage was curative.

Direct detection and amplification of Helicobacter pylori ribosomal 16S gene segments from gastric endoscopic biopsies

Helicobacter pylori is an organism thought to play an important causative role in gastritis and peptic ulcer diseases. We have designed an RNA dot blot assay for the detection of H. pylori, using as probe a synthetic oligonucleotide complementary to its 16S rRNA. We have also used oligonucleotide primers, complementary to conserved sequences within bacterial ribosomal 16S genes, to amplify a H. pylori ribosomal 16S DNA fragment via the polymerase chain reaction (PCR). After determining the DNA sequence of this amplified H. pylori fragment, primers were designed for specific PCR amplification of H. pylori ribosomal 16S DNA sequences. Samples from clinical endoscopic biopsies were PCR amplified with universal 16S ribosomal primers to detect the presence of bacteria and with H. pylori-specific primers to uniquely detect H. pylori. Finally, by comparing the H. pylori-specific PCR assay to commonly used diagnostic tests, we demonstrate that the molecular technique of PCR amplification shows promising applications for the clinical detection of H. pylori.

Prevalence of cryptosporidiosis in patients undergoing endoscopy: evidence for an asymptomatic carrier state

PURPOSE

We sought to determine the presence of the parasite cryptosporidium in the duodenal aspirates of patients undergoing routine upper gastrointestinal endoscopy.

PATIENTS AND METHODS

The study consisted of 169 patients undergoing upper endoscopy or endoscopic retrograde cholangiopancreatography. Immunocompromised patients were not included in the study population. Samples were aspirated from the second portion of the duodenum. Biopsy specimens were also obtained. Three randomly passed stool samples were obtained from 75% of the patients who were found to have cryptosporidium in the duodenum.

RESULTS

Overall, cryptosporidium oocysts were identified in 12.7% of patients. There was no significant difference in the prevalence of the parasite in any subgroup of procedure or symptom complex. Half of those (46.7%) with positive aspirates had demonstrable cryptosporidium in stool samples, although none of the patients had diarrhea. No patient had detectable cryptosporidium in biopsy samples of the duodenum.

CONCLUSION

The findings suggest a surprisingly high asymptomatic carrier rate for cryptosporidium.

Increasing incidence and excellent survival of patients with early gastric cancer: experience in a United States medical center

PURPOSE

In Japan, early gastric cancer has an excellent survival rate. In the United States, the disease is less well understood, and it is viewed more pessimistically, although we have previously shown in a small series of patients good short-term survival rates in early gastric cancer as compared with advanced gastric cancer. Our purpose in this study was to determine if the incidence of early gastric cancer and the associated survival rate has changed over a 24-year period.

PATIENTS AND METHODS

From the records at the Columbia Presbyterian Medical Center, 549 patients were identified who underwent gastric resection for cancer between 1960 and 1984, 69 of whom had early gastric cancer. Survival data were obtained in 63 patients. A comparison of survival rates was conducted between patients with early gastric cancer and the 1980 census figures.

RESULTS

Over the 24-year period, the total number of resections for gastric cancer at our institution declined. However, the percentage of gastric resections that satisfied the Japanese criteria for early gastric cancer increased from 9 percent between 1960 to 1974 to 17 percent between 1975 to 1984 (p less than 0.05). Of the 69 early gastric cancers, 35 percent involved the mucosa, whereas in 65 percent the malignancy invaded the submucosa. Twenty-eight percent had lymph node involvement. For the patients for whom survival data were available, survival was better than the 1980 census (p less than 0.05). The adjusted five-year survival rate was 97 percent. Neither submucosal invasion nor lymph node involvement altered survival. Patients with type III early cancers (ulcerated), however, had a significantly greater survival rate than patients with type I (polypoid) early cancers (p less than 0.05).

CONCLUSION

Early gastric cancer is being diagnosed with increasing frequency and has an excellent survival rate. These findings are similar to the Japanese experience and argue for an ongoing aggressive approach to endoscopic biopsy of gastric lesions.

Isolated ventral pancreatitis in an alcoholic with pancreas divisum

An alcoholic with no history of clinical pancreatitis was found to have pancreas divisum and marked changes of chronic pancreatitis isolated to the ventral pancreas. Pancreas divisum has been suggested to cause recurrent pancreatitis in some patients. Gross and histologic changes of pancreatitis in only the dorsal pancreas of surgically resected specimens from patients with pancreas divisum is thought to support the concept that obstruction at the minor papilla produces dorsal pancreatitis. Alternative explanations for the occurrence of segmental pancreatitis and the possible synergistic role of ethanol and bile are reviewed.

Giardia lamblia in patients undergoing endoscopy: lack of evidence for a role in nonulcer dyspepsia

Previous studies have suggested that Giardia lamblia may cause nonulcer dyspepsia as the sole manifestation of infection. To explore this premise, duodenal aspirates from patients undergoing upper endoscopy were examined for Giardia and results were correlated with endoscopic findings and symptoms. Of 155 patients, 15.5% had Giardia. Patients with dyspepsia, with or without obvious lesions at endoscopy, had a similar prevalence. Patients with vomiting and diarrhea had an increased prevalence (38.5%) (p less than 0.05). The prevalence of Giardia lamblia in this patient population is surprisingly high. This study suggests that Giardia lamblia infection is not a major cause of nonulcer dyspepsia.

Neoplasia in chronic erosive (varioliform) gastritis

Chronic erosive gastritis is a gastric mucosal lesion characterized by multiple, small, sessile elevations with central erosions. Symptoms typically resemble those in peptic ulcer disease. The elevations may persist and appear as sessile polyps after the erosions heal and symptoms resolve with therapy. Adenomatous transformation is reported in a patient with chronic erosive gastritis who had serial gastroscopies. This report suggests a possible association between chronic erosive gastritis and gastric neoplasia.

Malabsorption, hypocholesterolemia, and fat-filled enterocytes with increased intestinal apoprotein B. Chylomicron retention disease

Eight infants presented with a malabsorption syndrome, normal fasting triglycerides, hypocholesterolemia (64.3 +/- 10.0 mg/dl), and deficiency of vitamins A and E. Plasma low-density lipoprotein, apolipoprotein B, and apolipoprotein A-I were decreased. After a fatty meal, plasma triglycerides did not increase and chylomicrons could not be identified. Lipoprotein composition was characterized by normal apoproteins, high phospholipids, and low cholesterol. Increased triglycerides were present in low-density lipoproteins. Immunoperoxidase localization of apolipoprotein B on fasting biopsy specimens showed increased staining of the lipid-laden intestinal epithelial cells compared to normals. On electron microscopy after a fat load, the enterocytes contained large numbers of fat particles vesiculating the endoplasmic reticulum. These particles, morphologically similar to chylomicrons, were also present as aggregates of well-individualized lipid droplets within dilated vesicles in the Golgi zone, but were not seen in the intercellular spaces and lacteals. This recessively transmitted condition differs from abetalipoproteinemia and from the homozygous form of hypobetalipoproteinemia and may be caused by a defect in the final assembly of chylomicrons or in the mechanism of their exocytosis.

Blind loop syndrome, vitamin E malabsorption, and spinocerebellar degeneration

A 72-year-old man had severe malabsorption, progressive retinopathy, and spinocerebellar degeneration 32 years after gastric surgery, blind loop formation, and intestinal bacterial overgrowth. Clinical and pathologic features were typical of vitamin E deficiency; vitamin E was nearly undetectable in serum and profoundly low in adipose tissue. Vitamin E blood levels initially improved on treatment with antibiotics; after additional vitamin E supplementation, there was clinical improvement.

Early gastric cancer: radiographic experience

Early gastric cancer (EGC) is currently defined as an adenocarcinoma limited to the mucosa or to the mucosa and submucosa with or without perigastric lymph node involvement. To evaluate the radiologic features of this tumor, the radiographs of 21 cases were reviewed. Four were Type I (protruded) tumors, eight were Type II (superficial) including two mixed lesions, and nine were Type III (excavated), containing evidence of true ulceration. A retrospective analysis of radiographic findings indicated that nine of the tumors (43%) were either suspicious or diagnostic for malignancy on at least one examination, four (19%) were thought to be benign, and eight (38%) showed no identifiable lesion in the region of the stomach subsequently shown to contain an early cancer. The location, size, histology, gross morphology, and survival data, even in the face of perigastric lymph node involvement, all suggest that the early gastric cancer reported in this and other Western series is the same as that reported by the Japanese. The data further suggest that the incidence of EGC in the West is higher than traditionally thought.

A follow-up study of a third-party radiographic evaluation system

A follow-up study was conducted to evaluate the performance of the rating system for third-party carriers which was developed and instituted in 1976. Further, the technical quality of radiographs submitted under the system was evaluated. The conditions and parameters of the second study were identical to those of the original work. Statistical comparison of the data from both studies shows a significant decrease in the frequency of error occurrences over the 3-year span between the studies.

Alcohol, nutrition and malabsorption

Malabsorption occurs frequently in chronic alcoholics. Alcoholics may malabsorb fat, nitrogen, sodium, water, thiamine, folic acid, vitamin B12 and D-xylose. Malabsorption is due to an abnormal luminal phase of digestion as well as a diffuse functional mucosal abnormality. Malabsorption may, therefore, contribute to clinically significant malnutrition, diarrhoea, folate-deficiency and to abnormalities in tests of xylose and vitamin B12 absorption. Factors producing malabsorption in alcoholics include dietary folic acid and protein deficiency, pancreatic insufficiency, abnormalities of biliary secretions and direct effects of alcohol on the gastrointestinal tract. Many of the absorptive abnormalities are reversed when alcoholics are given a nutritious diet, even with continued intake of alcohol. This highlights the causal role of nutritional deficiencies in the malabsorption of chronic alcoholics.

Apolipoprotein localization and quantitation in the human intestine

Apolipoproteins B, A-I, and A-IV were localized in human intestinal epithelium using immunoperoxidase techniques. Staining was most obvious in villus tip cells. Lipid absorption resulted in an increase in intraepithelial staining for each apoprotein. The pattern for apo-B in the biopsy specimens taken after lipid absorption revealed a marked redistribution of staining to the intercellular spaces and an increase in the supranuclear staining of apo-A-I and apo-A-IV. After lipid absorption, staining appeared to extend further down the villus than in the fasting biopsy specimens. Quantitation of apo-A-I and apo-A-IV in isolated epithelial cells confirmed that the mass of these apoproteins increases in response to lipid absorption. Apolipoprotein B and apo-A-I were absent in the epithelium of 3 patients with abetalipoproteinemia while apo-A-IV was present in 2 patients. These studies demonstrate differences in the localization and quantitation of apoproteins in the villus-crypt unit as well as differences in the localization pattern of the different apoproteins.

Chronic erosive gastritis: clinical, diagnostic, and pathological features in nine patients

We have recognized nine patients with gastric mucosal lesions which were characterized by an erosion with surrounding mucosal elevation. This lesions has previously been called chronic erosive or varioliform gastritis. Patients were investigated because of upper gastrointestinal symptoms (n = 7), weight loss (n = 2), and/or bleeding (n = 3). Radiologically the appearance was of typical target lesions. Pathological features included pseudopyloric metaplasia, pyloric gland hyperplasia, acute and chronic inflammation, edema, and fibrosis. Atypia was present in biopsies from four patients and in one was incorrectly interpreted as representing intramucosal carcinoma. The remaining patients were treated with antacids and/or cimetidine with resolution of symptoms and in five patients repeat endoscopy demonstrated resolution of the lesions. Chronic erosive gastritis may cause upper gastrointestinal symptoms indistinguishable from peptic ulceration. Greater numbers of patients will have to be treated in a controlled fashion to determine the natural history of the disease and the most efficacious treatment.