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Denholm J, Schreiber BA, Jaeckle F, Wicks MN, Benbow EW, Bracey TS, Chan JYH, Farkas L, Fryer E, Gopalakrishnan K, Hughes CA, Kirkwood KJ, Langman G, Mahler-Araujo B, McMahon RFT, Myint KLW, Natu S, Robinson A, Sanduka A, Sheppard KA, Tsang YW, Arends MJ, Soilleux EJ. CD, or not CD, that is the question: a digital interobserver agreement study in coeliac disease. BMJ Open Gastroenterol 2024; 11:e001252. [PMID: 38302475 PMCID: PMC10870791 DOI: 10.1136/bmjgast-2023-001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/11/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVE Coeliac disease (CD) diagnosis generally depends on histological examination of duodenal biopsies. We present the first study analysing the concordance in examination of duodenal biopsies using digitised whole-slide images (WSIs). We further investigate whether the inclusion of immunoglobulin A tissue transglutaminase (IgA tTG) and haemoglobin (Hb) data improves the interobserver agreement of diagnosis. DESIGN We undertook a large study of the concordance in histological examination of duodenal biopsies using digitised WSIs in an entirely virtual reporting setting. Our study was organised in two phases: in phase 1, 13 pathologists independently classified 100 duodenal biopsies (40 normal; 40 CD; 20 indeterminate enteropathy) in the absence of any clinical or laboratory data. In phase 2, the same pathologists examined the (re-anonymised) WSIs with the inclusion of IgA tTG and Hb data. RESULTS We found the mean probability of two observers agreeing in the absence of additional data to be 0.73 (±0.08) with a corresponding Cohen's kappa of 0.59 (±0.11). We further showed that the inclusion of additional data increased the concordance to 0.80 (±0.06) with a Cohen's kappa coefficient of 0.67 (±0.09). CONCLUSION We showed that the addition of serological data significantly improves the quality of CD diagnosis. However, the limited interobserver agreement in CD diagnosis using digitised WSIs, even after the inclusion of IgA tTG and Hb data, indicates the importance of interpreting duodenal biopsy in the appropriate clinical context. It further highlights the unmet need for an objective means of reproducible duodenal biopsy diagnosis, such as the automated analysis of WSIs using artificial intelligence.
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Affiliation(s)
- James Denholm
- Department of Pathology, University of Cambridge, Cambridge, UK
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK
- Lyzeum Ltd, Cambridge, UK
| | - Benjamin A Schreiber
- Department of Pathology, University of Cambridge, Cambridge, UK
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK
| | - Florian Jaeckle
- Department of Pathology, University of Cambridge, Cambridge, UK
- Lyzeum Ltd, Cambridge, UK
| | - Mike N Wicks
- Department of Pathology, The University of Edinburgh College of Medicine and Veterinary Medicine, Edinburgh, UK
| | - Emyr W Benbow
- Division of Medical Education, The University of Manchester, Manchester, UK
- Department of Histopathology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Tim S Bracey
- Department of Diagnostic and Molecular Pathology, Royal Cornwall Hospitals NHS Trust, Truro, UK
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - James Y H Chan
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lorant Farkas
- Department of Pathology, Akershus University Hospital, Nordbyhagen, Norway
- Institute of Clinical Medicine, University of Oslo, Nordbyhagen, Norway
| | - Eve Fryer
- Department of Cellular Pathology, Oxford University Hospitals NHS foundation Trust, Oxford, UK
| | - Kishore Gopalakrishnan
- Department of Histopathology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Caroline A Hughes
- Department of Cellular Pathology, Oxford University Hospitals NHS foundation Trust, Oxford, UK
| | | | - Gerald Langman
- Department of Cellular Pathology, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Betania Mahler-Araujo
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- MRC Institute of Metabolic Science, Wellcome Trust, Cambridge, UK
| | - Raymond F T McMahon
- Division of Medical Education, The University of Manchester, Manchester, UK
- Department of Histopathology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Khun La Win Myint
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Sonali Natu
- University Hospital of North Tees, North Tees and Hartlepool NHS Foundation Trust, Stockton on Tees, UK
| | - Andrew Robinson
- Department of Histopathology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Ashraf Sanduka
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Katharine A Sheppard
- Department of Cellular Pathology, Oxford University Hospitals NHS foundation Trust, Oxford, UK
| | - Yee Wah Tsang
- Department of Histopathology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Mark J Arends
- Division of Pathology, University of Edinburgh, Edinburgh, UK
| | - Elizabeth J Soilleux
- Department of Pathology, University of Cambridge, Cambridge, UK
- Lyzeum Ltd, Cambridge, UK
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Schiepatti A, Sanders DS, Baiardi P, Caio G, Ciacci C, Kaukinen K, Lebwohl B, Leffler D, Malamut G, Murray JA, Rostami K, Rubio-Tapia A, Volta U, Biagi F. Nomenclature and diagnosis of seronegative coeliac disease and chronic non-coeliac enteropathies in adults: the Paris consensus. Gut 2022; 71:2218-2225. [PMID: 35676085 PMCID: PMC9554081 DOI: 10.1136/gutjnl-2021-326645] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/02/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Differential diagnosis of villous atrophy (VA) without coeliac antibodies in adults includes seronegative coeliac disease (CD) and chronic enteropathies unrelated to gluten, ie. non-coeliac enteropathies (NCEs). There is currently no international consensus on the nomenclature and diagnostic criteria for these enteropathies. In this work, a Delphi process was conducted to address this diagnostic and clinical uncertainty. DESIGN An international task force of 13 gastroenterologists from six countries was recruited at the 16th International Coeliac Disease Symposium, Paris, 2019. Between September 2019 and July 2021, a Delphi process was conducted through mail surveys to reach a consensus on which conditions to consider in the differential diagnosis of VA with negative coeliac serology and the clinical diagnostic approaches required for these conditions. A 70% agreement threshold was adopted. RESULTS Chronic enteropathies characterised by VA and negative coeliac serology can be attributed to two main clinical scenarios: forms of CD presenting with negative serology, which also include seronegative CD and CD associated with IgA deficiency, and NCEs, with the latter recognising different underlying aetiologies. A consensus was reached on the diagnostic criteria for NCEs assisting clinicians in differentiating NCEs from seronegative CD. Although in adults seronegative CD is the most common aetiology in patients with VA and negative serology, discriminating between seronegative CD and NCEs is key to avoid unnecessary lifelong gluten-free diet, treat disease-specific morbidity and contrast poor long-term outcomes. CONCLUSION This paper describes the Paris consensus on the definitions and diagnostic criteria for seronegative CD and chronic NCEs in adults.
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Affiliation(s)
- Annalisa Schiepatti
- Dipartimento di Medicina Interna e Terapia Medica, University of Pavia, Pavia, Italy .,Istituti Clinici Scientifici Maugeri, IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Paola Baiardi
- Direzione Scientifica Centrale, Fondazione S. Maugeri, IRCCS, Pavia, Italy
| | - Giacomo Caio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy,Celiac Center and Mucosal Immunology and Biology Research Center Massachusetts General Hospital- Harvard Medical School, Boston, Massachusetts, USA
| | - Carolina Ciacci
- AOU San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, Baronissi, Italy
| | - Katri Kaukinen
- Faculty of Medicine and Health Technology, Tampere University and Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York City, New York, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Daniel Leffler
- The Celiac Center at BIDMC, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Georgia Malamut
- Université de Paris, Department of Gastroenterology, AP-HP, Hôpital Cochin, Paris, France
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kamran Rostami
- Departments of Gastroenterology, Mid Central DHB, Palmerston Hospital, Palmerston North, Palmerston North, New Zealand
| | - Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Federico Biagi
- Dipartimento di Medicina Interna e Terapia Medica, University of Pavia, Pavia, Italy,Istituti Clinici Scientifici Maugeri, IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
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Aziz I, Peerally MF, Barnes JH, Kandasamy V, Whiteley JC, Partridge D, Vergani P, Cross SS, Green PH, Sanders DS. The clinical and phenotypical assessment of seronegative villous atrophy; a prospective UK centre experience evaluating 200 adult cases over a 15-year period (2000-2015). Gut 2017; 66:1563-1572. [PMID: 27605538 DOI: 10.1136/gutjnl-2016-312271] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/15/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Seronegative villous atrophy (SNVA) is commonly attributed to coeliac disease (CD). However, there are other causes of SNVA. More recently angiotensin-2-receptor-blockers (A2RBs) have been reported as an association but data on SNVA have been limited to centres evaluating complex case referrals and not SNVA in general. OBJECTIVES To provide clinical outcomes and associations in a large prospective study overseeing all newcomers with SNVA. DESIGN Over a 15-year period (2000-2015) we evaluated 200 adult patients with SNVA at a UK centre. A diagnosis of either seronegative CD (SNCD) or seronegative non-CD (SN-non-CD) was reached. Baseline comparisons were made between the groups, with 343 seropositive CD subjects serving as controls. RESULTS Of the 200 SNVA cases, SNCD represented 31% (n=62) and SN-non-CD 69% (n=138). The human leucocyte antigen (HLA)-DQ2 and/or DQ8 genotype was present in 61%, with a 51% positive predictive value for SNCD. The breakdown of identifiable causes in the SN-non-CD group comprised infections (27%, n=54), inflammatory/immune-mediated disorders (17.5%, n=35) and drugs (6.5%, n=13; two cases related to A2RBs). However, no cause was found in 18% (n=36) and of these 72% (n=26/36) spontaneously normalised duodenal histology while consuming a gluten-enriched diet. Following multivariable logistic regression analysis an independent factor associated with SN-non-CD was non-white ethnicity (OR 10.8, 95% CI 2.2 to 52.8); in fact, 66% of non-whites had GI infections. On immunohistochemistry all groups stained positive for CD8-T-cytotoxic intraepithelial lymphocytes. However, additional CD4-T helper intraepithelial lymphocytes were occasionally seen in SN-non-CD mimicking the changes associated with refractory CD. CONCLUSIONS Most patients with SNVA do not have CD, in particular those who are not white. Furthermore, a subgroup with no obvious aetiology will show spontaneous histological resolution while consuming gluten. These findings suggest caution in empirically prescribing a gluten-free diet without investigation.
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Affiliation(s)
- Imran Aziz
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK.,University of Sheffield, Sheffield, UK
| | - Mohammad F Peerally
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Jodie-Hannah Barnes
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK.,University of Sheffield, Sheffield, UK
| | - Vigneswaran Kandasamy
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK.,University of Sheffield, Sheffield, UK
| | - Jack C Whiteley
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK.,University of Sheffield, Sheffield, UK
| | - David Partridge
- Department of Microbiology, Royal Hallamshire Hospital, Sheffield, UK
| | - Patricia Vergani
- Department of Histopathology, Royal Hallamshire Hospital, Sheffield, UK
| | - Simon S Cross
- University of Sheffield, Sheffield, UK.,Department of Histopathology, Royal Hallamshire Hospital, Sheffield, UK
| | - Peter H Green
- Department of Medicine, Columbia University College of Physicians and Surgeons, Celiac Disease Center, New York, New York, USA
| | - David S Sanders
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK.,University of Sheffield, Sheffield, UK
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Deuring JJ, Fuhler GM, Konstantinov SR, Peppelenbosch MP, Kuipers EJ, de Haar C, van der Woude CJ. Genomic ATG16L1 risk allele-restricted Paneth cell ER stress in quiescent Crohn's disease. Gut 2014; 63:1081-91. [PMID: 23964099 DOI: 10.1136/gutjnl-2012-303527] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Although genome wide association studies have partly uncovered the genetic basis of Crohn's disease (CD), it remains a challenge to link genetic polymorphisms to functional intestinal phenotypes. Paneth cells are specialised antimicrobial epithelial cells localised to the small-intestinal crypt-base. Here, we investigate whether genomic variations in ATG16L1 affect Paneth cell function. DESIGN Genomic variation of ATG16L1 (T300A, rs2241880) was determined in DNA from 78 patients with CD and 12 healthy controls. Paraffin-embedded ileal biopsies from patients with genotype AA (n=17), GA (n=38) and patients with the GG allele (n=23) were stained for GRP78, phospho-EIF2α, lysozyme, cleaved-caspase 3, phosphohistone H3, phospho-IκB, p65, phospho-p38MAPK and PHLDA1. Microbial composition of biopsies was assessed by PCR. Disease phenotype was scored. RESULTS In patients with quiescent disease but with an ATG16L1 risk allele, the endoplasmic reticulum (ER) stress markers GRP78 and pEIF2α were highly expressed in Paneth cells. Other CD risk gene variations did not correlate with Paneth cell ER stress. Functionally, patients with ER-stressed Paneth cells showed no changes in intestinal epithelial cells proliferation or apoptosis, Paneth cell or stem cell numbers, p65, phospho-IκB and phospho-p38 staining. However, a significantly increased presence of adherent-invasive Escherichia coli was observed in biopsies from patients with ER-stressed Paneth cells. Phenotypically, patients with GRP78 positive Paneth cells have relatively less colonic disease over ileal disease (-21%, p=0.04), more fistulas (+21%, p=0.05) and an increased need for intestinal surgery (+38%, p=0.002). CONCLUSIONS The ATG16L1 T300A polymorphism defines a specific subtype of patients with CD, characterised by Paneth cell ER stress even during quiescent disease. Paneth cell ER stress correlates with bacterial persistence, and is thus likely to modulate antimicrobial functionality of this cell type in patients with CD.
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Affiliation(s)
- J Jasper Deuring
- Department Gastroenterology and Hepatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Gwenny M Fuhler
- Department Gastroenterology and Hepatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sergey R Konstantinov
- Department Gastroenterology and Hepatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Maikel P Peppelenbosch
- Department Gastroenterology and Hepatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department Gastroenterology and Hepatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Colin de Haar
- Department Gastroenterology and Hepatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - C Janneke van der Woude
- Department Gastroenterology and Hepatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
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