Celiac disease

The relationship of autism and gluten

BACKGROUND

Autism is now a common condition with a prevalence of 1 in 88 children. There is no known etiology. Speculation about possible treatments for autism or autism spectrum disorders (ASD) has included the use of various dietary interventions, including a gluten-free diet.

OBJECTIVE

The goal of this article was to review the literature available evaluating the use of gluten-free diets in patients with autism to determine if diet should be instituted as a treatment.

METHODS

A literature review was performed, identifying previously published studies in which a gluten-free diet was instituted as an autism treatment. These studies were not limited to randomized controlled trials because only 1 article was available that used a double-blind crossover design. Most publish reports were unblinded, observational studies.

RESULTS

In the only double-blind, crossover study, no benefit of a gluten-free diet was identified. Several other studies did report benefit from gluten-free diet. Controlling for observer bias and what may have represented unrelated progress over time in these studies is not possible. There are many barriers to evaluating treatment benefits for patients with autism. Gluten sensitivity may present in a variety of ways, including gastrointestinal and neurologic symptoms. Although making a diagnosis of celiac disease is easier with new serology and genetic testing, a large number of gluten-sensitive patients do not have celiac disease. Testing to confirm non-celiac gluten sensitivity is not available.

CONCLUSIONS

A variety of symptoms may be present with gluten sensitivity. Currently, there is insufficient evidence to support instituting a gluten-free diet as a treatment for autism. There may be a subgroup of patients who might benefit from a gluten-free diet, but the symptom or testing profile of these candidates remains unclear.

The prevalence of antibodies against wheat and milk proteins in blood donors and their contribution to neuroimmune reactivities

The aim of this study was to look for the presence of IgG, IgM, and IgA antibodies against two widely consumed foods, wheat and milk, in a relatively large number of specimens. As wheat, milk, and their antigens have been found to be involved in neuroimmune disorders, we measured the co-occurrence of their antibodies against various neural antigens. We assessed the reactivity of sera from 400 donors to wheat and milk proteins, GAD-65, cerebellar, MBP, and MOG. Statistical analysis showed significant clustering when certain wheat and milk protein antibodies were cross-referenced with neural antibodies. Approximately half of the sera with antibody elevation against gliadin reacted significantly with GAD-65 and cerebellar peptides; about half of the sera with elevated antibodies against α + β-casein and milk butyrophilin also showed antibody elevation against MBP and MOG. Inhibition studies showed that only two out of four of the samples with elevated cerebellar or MOG antibodies could be inhibited by gliadin or α + β-casein, confirming individual variation in epitope recognition. We conclude that a subgroup of blood donors, due to a breakdown in immunological tolerance, may react and produce significant levels of antibodies (p-values less than 0.05) against wheat and milk antigens that cross-react with different neural antigens, which may have broader implications in the induction of neuroimmune reactivities.

The tip of the "celiac iceberg" in China: a systematic review and meta-analysis

Objective

Until recently, celiac disease was considered to be rare in China. We aimed to estimate its true status.

Methods

By searching the MEDLINE database and four Chinese full-text databases (CNKI, CBM, VIP and WANFANG) (up to August 2012), as well as two HLA allele frequency net databases and the Chinese Statistics Yearbook databases, we systematically reviewed the literature on definite and suspected cases of celiac disease, the predisposing HLA allele frequencies, and on gluten exposure in China. Meta-analysis was performed by analyzing DQ2, DQ8 and DQB1*0201 gene frequencies and heterogeneity in populations from different geographic regions and ethnicities in China.

Results

At present, the number of reported celiac disease cases is extremely low in China. The frequencies of the HLA-DQ2.5 and HLA-DQ8 haplotypes were 3.4% (95% confidence interval 1.3–5.5%) and 2.1% (0.1–4.1%), respectively. HLA-DQ2 and HLA-DQ8 antigen frequencies were 18.4% (15.0–21.7%) and 8.0% (4.5–11.4%), respectively. The frequency of the DQB1*0201 allele was 10.5% (9.3–11.6%) and it was more common in the northern Chinese than in the southern Chinese populations. The chance of being exposed to gluten is rapidly increasing all over China nowadays.

Conclusion

The data on HLA haplotyping, in conjunction with increasing wheat consumption, strongly suggests that the occurrence of celiac disease is more common in China than currently reported. Coordinated measures by the Chinese government, medical and agricultural research institutions, and food industries, would be justified to create more awareness about celiac disease and to prevent it becoming a medical and societal burden.

Improving the stability and activity of oral therapeutic enzymes-recent advances and perspectives

Exogenous, orally-administered enzymes are currently in clinical use or under development for the treatment of pathologies, such as celiac disease and phenylketonuria. However, the administration of therapeutic enzymes via the oral route remains challenging due to potential inactivation of these fragile macromolecular entities in the harsh environment of the gastrointestinal tract. Enzymes are particularly sensitive because both proteolysis and unfolding can lead to their inactivation. Current efforts to overcome these shortcomings involve the application of gastro-resistant delivery systems and the modification of enzyme structures by polymer conjugation or protein engineering. This perspective manuscript reviews and critically discusses recent progress in the oral delivery of therapeutic enzymes, whose substrate is localized in the gastrointestinal tract.

Germination of oat and quinoa and evaluation of the malts as gluten free baking ingredients

Germination can be used to improve the sensory and nutritional properties of cereal and pseudocereal grains. Oat and quinoa are rich in minerals, vitamins and fibre while quinoa also contains high amounts of protein of a high nutritional value. In this study, oat and quinoa malts were produced and incorporated in a rice and potato based gluten free formulation. Germination of oat led to a drastic increase of α-amylase activity from 0.3 to 48 U/g, and minor increases in proteolytic and lipolytic activities. Little change was observed in quinoa except a decrease in proteolytic activity from 9.6 to 6.9 U/g. Oat malt addition decreased batter viscosities at both proofing temperature and during heating. These changes led to a decrease in bread density from 0.59 to 0.5 g/ml and the formation of a more open crumb, but overdosing of oat malt deteriorated the product as a result of excessive amylolysis during baking. Quinoa malt had no significant effect on the baking properties due to low α-amylase activity. Despite showing a very different impact on the bread quality, both malts influenced the electrophoretic patterns of rice flour protein similarly. This suggests that malt induced proteolysis does not influence the technological properties of a complex gluten free formulation.

Differentiation between Celiac Disease, Nonceliac Gluten Sensitivity, and Their Overlapping with Crohn's Disease: A Case Series

Celiac disease (CD) and nonceliac gluten sensitivity (NCGS) are two distinct conditions triggered by the ingestion of gliadin. Although symptoms of nonceliac gluten sensitivity may resemble those of celiac disease, due to the lack of objective diagnostic tests, NCGS is associated with overlapping symptomatologies of autoimmunities and Crohn's disease. Furthermore, a gluten-free diet is only recommended for those who meet the criteria for a diagnosis of CD. Unfortunately, that leaves many nonceliac gluten-sensitive people suffering unnecessarily from very serious symptoms that put them at risk for complications of autoimmune disorders that might be resolved with a gluten-free diet. Thus, a new paradigm is needed for aid in diagnosing and distinguishing among various gut-related diseases, including CD, NCGS (also known as silent celiac disease), and gut-related autoimmunities. Herein, we report three different cases: the first, an elderly patient with celiac disease which was diagnosed based on signs and symptoms of malabsorption and by a proper lab test; second, a case of NCGS which was initially misdiagnosed as lupus but was detected as NCGS by a proper lab test with its associated autoimmunities, including gluten ataxia and neuromyelitis optica; third, a patient with NCGS overlapping with Crohn's disease. The symptomatologies of all three patients improved significantly after 12 months of gluten-free diet plus other modalities.

Celiac and Non-Celiac Forms of Gluten Sensitivity: Shifting Paradigms of an Old Disease

Gluten sensitivity is one of the prominent features of celiac disease (CD) which is an autoimmune disorder characterized by damaged lining of the small intestine. CD was known already to ancient Greeks as κοιλιακός (keeleeakoss) i.e. disease of the abdominal cavity hence celiac. Focus of this Commentary article is on rather complex definition of CD and its emerging new forms the example of which is non-celiac gluten sensitivity. It is becoming evident that to formulate more effective treatments, these associations and newly identified disease entities deserve attention from both academic and clinical communities.

Might gluten traces in wheat substitutes pose a risk in patients with celiac disease? A population-based probabilistic approach to risk estimation

BACKGROUND

In patients with treated celiac disease (CD), the ingestion of gluten traces contained in gluten-free (GF) wheat substitutes (eg, GF bread, flour, and pasta) could cause persisting intestinal mucosal damage.

OBJECTIVE

The objective was to evaluate the proportion of CD patients at risk of mucosal damage due to the consumption of GF products in 4 European countries (Italy, Spain, Germany, and Norway).

DESIGN

A probabilistic modeling approach was used to assess the risk of gluten intake at the population level. The input variables were 1) consumption of GF products, 2) concentration of gluten traces in GF products determined by the sandwich R5 ELISA method, and 3) the gluten threshold for mucosal damage of 10 to 50 mg/d. Different population and product availability scenarios were examined for risk assessment.

RESULTS

The gluten content of 205 commercially available GF products ranged between <5 and 27.8 mg/kg. Overall, 99.5% of the analyzed samples had a gluten concentration <20 mg/kg. Most (94%) had a gluten concentration below the limit of quantification (5 mg/kg). The mean percentage of the CD European population at risk of mucosal damage resulting from consumption of GF products ranged between 0.01 (Germany) and 0.15 (Italy) and remained very low, even in the worst-case scenario (<1%).

CONCLUSIONS

The adoption of a single gluten threshold (20 mg/kg) for gluten contamination is suggested. GF products in Europe constitute a very safe option for patients with CD. The dietary follow-up of CD patients should focus on other potential sources of gluten contamination.

Endoscopic and histological gastric lesions in children with celiac disease: mucosal involvement is not only confined to the duodenum

OBJECTIVES

Lymphocytic gastritis (LG) has been reported in patients with celiac disease (CD). The aim of the present study was to evaluate gastric mucosa involvement in celiac children and gastroenterological controls (GC).

METHODS

In a retrospective study on 226 patients with CD (82  M; median age: 5.7 years) at diagnosis and 154 GC (66  M; median age: 7.4 years), the evaluation of gastric and duodenal mucosa was performed. CD was diagnosed according to the North America Society for Pediatric Gastroenterology, Hepatology, and Nutrition criteria. Gastric lesions were classified according to Updated Sydney System. Anti-gastric parietal cell antibodies (GPCA) were assayed by enzyme-linked immunosorbent assay.

RESULTS

A total of 21.2% and 7% of patients with CD showed chronic superficial gastritis (CSG) and LG, respectively. Helicobacter pylori (Hp) infection was found in 6 (2.7%) children with CD (66.7% had CSG, 16.7% LG, and 16.7% interstitial gastritis). CSG was present in 21.4% of controls. No control subject showed LG. Hp infection was found in 24 (15.6%) children with GC (91.7% had CSG). Among patients with CSG, Hp infection was more frequent in controls than in celiac children (P < 0.0001). Ten of 90 patients with CD and 1 of 29 controls were positive for GPCA.

CONCLUSIONS

Gastritis is a common finding in children with CD and adolescents. In celiac subjects, CSG is the most frequently detected. Our data suggest the hypothesis that LG may be related to a longer exposure to gluten. The presence of GPCA may suggest the presence of an underlying autoimmune process.

HLA-DQA1 and HLA-DQB1 in Celiac disease predisposition: practical implications of the HLA molecular typing

Celiac disease (CD) is a multifactorial disorder with an estimated prevalence in Europe and USA of 1:100 and a female:male ratio of approximately 2:1. The disorder has a multifactorial etiology in which the triggering environmental factor, the gluten, and the main genetic factors, Human Leukocyte Antigen (HLA)-DQA1 and HLA-DQB1 loci, are well known. About 90-95% of CD patients carry DQ2.5 heterodimers, encoded by DQA1*05 and DQB1*02 alleles both in cis or in trans configuration, and DQ8 molecules, encoded by DQB1*03:02 generally in combination with DQA1*03 variant. Less frequently, CD occurs in individuals positive for the DQ2.x heterodimers (DQA1≠*05 and DQB1*02) and very rarely in patients negative for these DQ predisposing markers. HLA molecular typing for Celiac disease is, therefore, a genetic test with a negative predictive value. Nevertheless, it is an important tool able to discriminate individuals genetically susceptible to CD, especially in at-risk groups such as first-degree relatives (parents, siblings and offspring) of patients and in presence of autoimmune conditions (type 1 diabetes, thyroiditis, multiple sclerosis) or specific genetic disorders (Down, Turner or Williams syndromes).

The irritable bowel syndrome-celiac disease connection

Irritable bowel syndrome (IBS) is a prevalent functional gastrointestinal disorder that has a significant impact on quality of life and health care resources. Celiac disease (CD), a gluten-sensitive enteropathy, can be mistaken for IBS. This article discusses the connection between IBS and CD and the new concept of nonceliac gluten sensitivity (NCGS). NCGS may occur in the presence of a normal or near-normal small bowel biopsy. Some patients with IBS without CD may derive symptomatic benefit from a gluten-free diet. Future research could facilitate a significant impact on the quality of life in this potential subgroup of patients.

Triagem sorológica para doença celíaca em adolescentes e adultos jovens, estudantes universitários

OBJETIVOS: avaliar a positividade sorológica para doença celíaca em um grupo de adolescentes e adultos jovens da cidade do Recife, Nordeste do Brasil. MÉTODOS: a amostra foi composta por estudantes matriculados nos cursos de graduação do Centro de Ciências da Saúde da Universidade Federal de Pernambuco. Os estudantes foram submetidos à coleta de sangue para pesquisa sorológica do anticorpo antitransglutaminase tecidual humana e responderam a questionário sobre sintomas e condições mórbidas associadas à doença celíaca. O anticorpo antitrans-glutaminase foi pesquisado por técnica de Elisa, considerando-se positivos valores acima de 10 U/mL, conforme estabelecido pelo fabricante. Nos pacientes que tiveram sorologia positiva para o anticorpo antitransglutaminase realizou-se a sorologia para o anticorpo antiendomíseo, por imunofluorescência indireta, utilizando kit comercialmente disponível. RESULTADOS: seiscentos e oitenta e três universitários participaram da pesquisa. Os estudantes tinham entre 18 e 30 anos e mediana de idade de 21 anos. O anticorpo antitransglutaminase foi positivo em 12/683, soroprevalência de 1,76% (IC95%: 0,95-3,13%). O anticorpo antiendomíseo foi realizado em 11 amostras e reagente em quatro. Oito estudantes com sorologia positiva tinham sintomas e/ou condições mórbidas associadas à doença celíaca. CONCLUSÕES: a elevada presença de anticorpos anti-transglutaminase encontrada neste estudo é semelhante a da Europa e Estados Unidos da América, sugere a possibilidade da triagem sorológica mesmo em populações consideradas de baixo risco.

Duodenal bulb in celiac adults: the "whether biopsying" dilemma

BACKGROUND

Celiac disease (CD)-related lesions were described in duodenal bulb of celiac patients.

GOAL

Our aim was to evaluate the morphology of bulb mucosa in adult celiac patients and in controls to evaluate its usefulness for CD diagnosis.

STUDY

We studied 43 celiac patients (10 male, median age: 35.2 y) at diagnosis and 43 gastroenterological controls (10 male, median age: 37.8 y), submitted to upper endoscopy for gastroenterological complaints. Histologic lesions were assayed by an experienced pathologist according to the Marsh modified classification. Antiendomysium antibodies and antitransglutaminase antibodies-tTGAb (ELISA and/or RIA) have been tested. In selected patients, DNA was typed for DRB1, DQA1, and DQB1 genes by sequence-specific primer polymerase chain reaction.

RESULTS

In all celiac patients lesions were present in the bulb mucosa. One female with thyroiditis, who had a CD daughter, showed lesions only in the duodenal bulb. Patchy villous atrophy was found in another patient. All celiacs were antiendomysium and/or tTGAb positive. DQ2 heterodimer was present in 5 CD patients. The gastroenterological controls showed normal mucosa in the duodenum.

CONCLUSIONS

This study demonstrates that CD-related histologic lesions are present in duodenal bulb of adult patients. Moreover, the normal aspect of this mucosa in gastroenterological controls implies the high negative predictive value of this finding. Therefore, we suggest taking at least 1 biopsy on the bulb area and 1 from the distal duodenum for CD diagnosis, in all the patients submitted to upper endoscopy, to avoid missed or delayed diagnosis.

Proof of concept of microbiome-metabolome analysis and delayed gluten exposure on celiac disease autoimmunity in genetically at-risk infants

Celiac disease (CD) is a unique autoimmune disorder in which the genetic factors (DQ2/DQ8) and the environmental trigger (gluten) are known and necessary but not sufficient for its development. Other environmental components contributing to CD are poorly understood. Studies suggest that aspects of gluten intake might influence the risk of CD occurrence and timing of its onset, i.e., the amount and quality of ingested gluten, together with the pattern of infant feeding and the age at which gluten is introduced in the diet. In this study, we hypothesize that the intestinal microbiota as a whole rather than specific infections dictates the switch from tolerance to immune response in genetically susceptible individuals. Using a sample of infants genetically at risk of CD, we characterized the longitudinal changes in the microbial communities that colonize infants from birth to 24 months and the impact of two patterns of gluten introduction (early vs. late) on the gut microbiota and metabolome, and the switch from gluten tolerance to immune response, including onset of CD autoimmunity. We show that infants genetically susceptible to CD who are exposed to gluten early mount an immune response against gluten and develop CD autoimmunity more frequently than at-risk infants in which gluten exposure is delayed until 12 months of age. The data, while derived from a relatively small number of subjects, suggest differences between the developing microbiota of infants with genetic predisposition for CD and the microbiota from infants with a non-selected genetic background, with an overall lack of bacteria of the phylum Bacteriodetes along with a high abundance of Firmicutes and microbiota that do not resemble that of adults even at 2 years of age. Furthermore, metabolomics analysis reveals potential biomarkers for the prediction of CD. This study constitutes a definite proof-of-principle that these combined genomic and metabolomic approaches will be key to deciphering the role of the gut microbiota on CD onset.

Spectrum of gluten-related disorders: consensus on new nomenclature and classification

A decade ago celiac disease was considered extremely rare outside Europe and, therefore, was almost completely ignored by health care professionals. In only 10 years, key milestones have moved celiac disease from obscurity into the popular spotlight worldwide. Now we are observing another interesting phenomenon that is generating great confusion among health care professionals. The number of individuals embracing a gluten-free diet (GFD) appears much higher than the projected number of celiac disease patients, fueling a global market of gluten-free products approaching $2.5 billion (US) in global sales in 2010. This trend is supported by the notion that, along with celiac disease, other conditions related to the ingestion of gluten have emerged as health care concerns. This review will summarize our current knowledge about the three main forms of gluten reactions: allergic (wheat allergy), autoimmune (celiac disease, dermatitis herpetiformis and gluten ataxia) and possibly immune-mediated (gluten sensitivity), and also outline pathogenic, clinical and epidemiological differences and propose new nomenclature and classifications.

Celiac disease and sensorineural hearing loss in children

CONCLUSION

Sensorineural hearing loss (SNHL) is a neurological situation and celiac disease (CD) may be seen coincidentally. Children with clinical signs of hearing deficiency of unknown etiology should be assessed for CD.

OBJECTIVE

CD is a chronic inflammatory gluten-dependent intestinal disease and has extraintestinal findings. The aim of this study was to determine the incidence of CD and SNHL in our pediatric patients.

METHODS

A total of 25 pediatric patients (50 ears) with biopsy-proven CD were diagnosed in the pediatric gastroenterology department; 25 healthy control subjects (50 ears) were also included in the study. All subjects underwent pure tone audiometry at frequencies of 250-8000 Hz and tympanometry.

RESULTS

In the patients and controls, normal peak compliance, gradient, peak pressure, ear canal volume, and acoustic reflexes were obtained by tympanometry. There was no air-bone gap in any of the participants. There was a statistically significant difference between the audiometric results in the CD and control groups (right ear and left ear) (p < 0.05).

Biochemical and immunochemical characterization of different varieties of amaranth (Amaranthus L. ssp.) as a safe ingredient for gluten-free products

Celiac disease is a food intolerance triggered by the ingestion of gluten-containing cereals; the only therapy is a strict gluten-free diet for life. In recent years, amaranth flour has received considerable attention as an interesting source for the formulation of gluten-free products due to its high nutritional value and low content of prolamins, the toxic proteins for celiacs. The aim of this study was to characterize 40 amaranth varieties using both SDS-PAGE/immunoblotting and ELISA to assess their possible tolerance by celiac subjects. All of the amaranth samples studied showed similar binding affinities for both specific anti-gliadin antibodies and human IgAs. In most amaranth grains, the content of gluten-like proteins measured by ELISA was <20 ppm. The molecular characterization of amaranth proteins suggests that amaranth is safe for celiacs to consume. It is recommended that the most suitable amaranth varieties are those having the lowest content of proteins cross-reacting with anti-gliadin antibodies.

Gluten contamination in the Canadian commercial oat supply

A growing body of evidence suggests that a majority of people with celiac disease and on a gluten-free diet can safely consume pure oats in moderate amounts; however, previous studies have indicated that the commercial oat supply in other countries, and in Canada to some extent, is contaminated with other grains. This study has confirmed that the commercial oat supply in Canada is heavily contaminated with gluten from other grains. Approximately 88% of the oat samples (n = 133) were contaminated above 20 mg kg⁻¹ and there were no differences between the oat types tested. Only one gluten-free variety of oats was analysed and it consistently provided negative results in all analyses. It is difficult to determine where the contamination originates, but there are possibilities for cross-contamination in the field, in the transport of the grain, in the storage of the grain, and in the milling and packaging facilities. It is clear from this study that only those products that have been certified ‘pure’ oats would be appropriate for a gluten-free diet.

Coeliac disease in Libyan children: a screening study based on the rapid determination of anti-transglutaminase antibodies

BACKGROUND

Coeliac disease is a common disorder in North Africa; however, there are no data on coeliac disease prevalence in Libya.

AIM

(1) To determine coeliac disease prevalence in Libyan schoolchildren by screening with a rapid test for IgA anti-transglutaminase determination on a blood drop; (2) to evaluate the accuracy of the rapid anti-transglutaminase test.

PATIENTS AND METHODS

We screened 2920 students (1452 females and 1468 males) attending school in El Beida (Libya) by the rapid anti-transglutaminase test. Conventional ELISA anti-transglutaminase in rapid test positives and small intestinal biopsy in ELISA positives were performed for coeliac disease diagnosis. Conventional IgA anti-transglutaminase was performed also in 800 rapid test negative subjects.

RESULTS

The rapid anti-transglutaminase test was positive in 50/2920 (1.7%) subjects but only 20/50 were confirmed by the ELISA determination. The diagnosis of coeliac disease was biopsy-confirmed in 19 out of these 20. The serum ELISA IgA anti-transglutaminase was positive in 4 out of 800 rapid test negative children. Coeliac disease prevalence was 0.79-1.13%.

CONCLUSIONS

Coeliac disease in Libyan children is as common as in Europe, affecting around 1% of the general population. The rapid test for IgA anti-transglutaminase determination on a blood drop was not an efficient screening test.

Micronutrient deficiencies in patients with typical and atypical celiac disease

OBJECTIVE

The extent of the digestive/absorptive involvement in atypical presentation of celiac disease (CD) is not always clear. The aim of the study was to assess nutritional status of iron (Fe), copper (Cu), and zinc (Zn) in patients with typical CD (TCD) and atypical CD (ACD).

PATIENTS AND METHODS

A cross-sectional study was done in patients with TCD, ACD, and healthy controls (HC). Hemoglobin, serum ferritin, free erythrocyte protoporphyrin, Fe, Cu, ceruloplasmin, Zn, anti-endomysial antibodies, and anti-tissue transglutaminase antibodies were measured. Data were analyzed by Kruskal-Wallis, principal component analysis, and linear discriminant analysis.

RESULTS

: One hundred nine individuals were studied (54 TCD, 19 ACD, 36 HC); mean age  ±  standard deviation was 23 ± 15.8 (range 1.6-75.4) years. Median and range of hemoglobin were 12.8 g/dL (8.1-17.6) in TCD, 12.4 g/dL (10.5-14.5) in ACD, and 13.6 g/dL (11.1-16.7) in HC (P < 0.0001); serum ferritin was 17.7 μg/L (2.9-157), 10.8 μg/L (2.7-39.8), and 28.7 μg/L (4.5-127.2), respectively (P < 0.01). Cu was 105 μg/dL (60-185), 97.5 μg/dL (40-130), and 125 μg/dL (80-205), respectively (P < 0.05). Ceruloplasmin was 21.6  mg/dL (14.2-73.2), 22.6  mg/dL (0.9-34.3), and 32.1 mg/dL (5.8-72.6), respectively (P < 0.01). There were no differences in Fe, free erythrocyte protoporphyrin, and Zn. Principal component analysis showed that 58% of observed variability was explained by Fe and Cu indicators. Linear discriminant analysis revealed differences between CD and HC (P < 0.0001), with high values of correct classification for TCD (73%) and HC (72%), but not ACD (16%), which were mostly classified as TCD (79%).

CONCLUSIONS

Deficiency of micronutrients was found both in typical as well as in atypical cases.

Expression of Zonulin, c-kit, and Glial Fibrillary Acidic Protein in Human Gliomas

The hallmarks of human malignant gliomas are their marked invasiveness and vascularity. Because angiogenesis and tumor invasion have been associated with extracellular matrix degradation and intercellular tight junctions, the involvement of zonulin in glioma biology is in the focus. We selected for histological examination five cases of glioblastoma WHO IV (nomenclature of the World Health Organization) and one case each from astrocytoma WHO III, meningioma WHO III, and meningioma WHO I as control samples. The meningioma WHO I is regarded as benign, whereas the meningioma WHO III is recognized as the transition form of malignant tumors in humans. The visualization of a newly designed antibody against human zonulin was studied in triple-labeling studies using fluorescence immunocytochemistry and compared with the expression of c-kit and glial fibrillary acidic protein in differently developed human gliomas. We found that increasing the expression of c-kit is accompanied by an increase of zonulin expression. Both are correlated to the degree of malignancy of human brain tumors. The expression of zonulin is correlated to the degradation of the blood-brain barrier as revealed by Griffonia simplicifolia lectin. In differently graded tumors, we found differently graded involvement of blood vessels in the tumor development, explaining patients' survival.

In vivo fluorescence imaging of exogenous enzyme activity in the gastrointestinal tract

Exogenous enzymes are administered orally to treat several diseases, such as pancreatic insufficiency and lactose intolerance. Due to the proteinaceous nature of enzymes, they are subject to inactivation and/or digestion in the gastrointestinal (GI) tract. Here we describe a convenient fluorescence-based assay to monitor the activity of therapeutic enzymes in real time in vivo in the GI tract. To establish the proof of principle, the assay was applied to proline-specific endopeptidases (PEPs), a group of enzymes recently proposed as adjuvant therapy for celiac disease (a highly prevalent immunogenetic enteropathy). A short PEP-specific peptide sequence which is part of larger immunotoxic sequences of gluten was labeled with a fluorescent dye and a corresponding quencher. Upon enzymatic cleavage, the fluorescence emission was dequenched and detected with an in vivo imaging system. PEPs originating from Flavobacterium meningosepticum (FM) and Myxococcus xanthus (MX) were evaluated after oral administration in rats. While MX PEP could not cleave the peptide in the stomach, FM PEP showed significant gastric activity reaching 40-60% of the maximal in vivo signal intensity. However, both enzymes produced comparable fluorescence signals in the small intestine. Coadministration of an antacid drug significantly enhanced MX PEP's gastric activity due to increased pH and/or inhibition of stomach proteases. With this simple procedure, differences in the in vivo performance of PEPs, which could not be identified under in vitro conditions, were detected. This imaging assay could be used to study other oral enzymes in vivo and therefore be instrumental in improving their therapeutic efficiency.

Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: celiac disease and gluten sensitivity

BACKGROUND

Celiac disease (CD) is an autoimmune enteropathy triggered by the ingestion of gluten. Gluten-sensitive individuals (GS) cannot tolerate gluten and may develop gastrointestinal symptoms similar to those in CD, but the overall clinical picture is generally less severe and is not accompanied by the concurrence of tissue transglutaminase autoantibodies or autoimmune comorbidities. By studying and comparing mucosal expression of genes associated with intestinal barrier function, as well as innate and adaptive immunity in CD compared with GS, we sought to better understand the similarities and differences between these two gluten-associated disorders.

METHODS

CD, GS and healthy, gluten-tolerant individuals were enrolled in this study. Intestinal permeability was evaluated using a lactulose and mannitol probe, and mucosal biopsy specimens were collected to study the expression of genes involved in barrier function and immunity.

RESULTS

Unlike CD, GS is not associated with increased intestinal permeability. In fact, this was significantly reduced in GS compared with controls (P = 0.0308), paralleled by significantly increased expression of claudin (CLDN) 4 (P = 0.0286). Relative to controls, adaptive immunity markers interleukin (IL)-6 (P = 0.0124) and IL-21 (P = 0.0572) were expressed at higher levels in CD but not in GS, while expression of the innate immunity marker Toll-like receptor (TLR) 2 was increased in GS but not in CD (P = 0.0295). Finally, expression of the T-regulatory cell marker FOXP3 was significantly reduced in GS relative to controls (P = 0.0325) and CD patients (P = 0.0293).

CONCLUSIONS

This study shows that the two gluten-associated disorders, CD and GS, are different clinical entities, and it contributes to the characterization of GS as a condition associated with prevalent gluten-induced activation of innate, rather than adaptive, immune responses in the absence of detectable changes in mucosal barrier function.

What do Brazilian pediatricians know about celiac disease?

INTRODUCTION

Celiac disease (CD) is a common illness, affecting 0.5-1% of the population. Its classic presentation consists of gastrointestinal symptoms, however, many extra-intestinal symptoms and some associated diseases have been studied. Pediatricians should know the typical and atypical presentations of CD and how to diagnosis and treat its complications. The aim of this study was describe what pediatricians in Brazil know about CD.

METHODS

A descriptive, cross-sectional study with pediatricians who participated in the Nestlé Pediatrics Course, in the city of Natal, Brazil, in 2008. They were asked to complete a self-applicable questionnaire covering aspects concerning the prevalence, diagnosis, and treatment of CD and the conditions associated with this disease.

RESULTS

A total of 632 pediatricians completed the questionnaire. The majority of respondents (82.9%) were female. All the geographical regions of Brazil were represented. More than 65% of respondents had undergone specialist training in pediatrics, and 40% of respondents had worked as pediatricians for more than 25 years. Only 22% replied that celiac disease may be asymptomatic, 57% stated that antigliadin antibody measurement represents the best screening tool for the disease, and two-thirds replied that bowel biopsy would be the most indicated method. The pathologies and conditions associated with celiac disease were identified by fewer than 50% of respondents. Exclusion of gluten from the patient's diet was mentioned as the treatment for celiac disease by 86.4% of the pediatricians.

CONCLUSIONS

We conclude that pediatricians have superficial information about CD. The need for relevant information on celiac disease is fundamental and is recognized by the pediatricians themselves.

Sensorineural hearing loss in pediatric celiac patients

OBJECTIVE

Celiac disease (CD) is an immune-mediated chronic inflammatory gluten-dependent intestinal disease affecting 0.5-1% of the general population worldwide. CD is underdiagnosed even with sophisticated health care; approximately 10% of people affected by CD are now diagnosed. The recognition of the atypical extra-intestinal manifestations, including neurological disorders increased the diagnosis of CD. At present, no data are available on the presence of sensorineural hearing loss in pediatric CD patients. The aim of this study was to determine the incidence and severity of sensorineural hearing loss (SNHL) in different frequencies in pediatric CD patients.

METHODS

A sample of 32 biopsies and serologically proven newly diagnosed pediatric CD patients (CD group) (64 ears) and 32 sex and age-matched healthy subjects (64 ears) as control group (C group) were included in this study. Anthropometric measurements, physical examinations including ear nose and throat and pure-tone audiometry at frequencies 250-8000 Hz were performed in all subjects in both groups. Slight/mild SNHL was defined as a loss of detection of sound within the 16-40 dB range. The mean age of patient and control group was 11.9 and 11.3, respectively (p>0.05).

RESULTS

In CD group, sensorineural hearing loss was found in 13 (40.6%) patients (group A) as it was bilateral in six and unilateral in seven patients. In control group (group C), slight/mild SNHL was found in one (3.1%) subject. The frequency of hearing loss was significantly higher in CD group than in group C (p<0.001).

CONCLUSION

The present study showed a higher prevalence of sensory neural hearing loss in pediatric celiac patients than in healthy controls, suggesting an association between CD and SNHL. The findings of this study suggest that hearing impairment should be searched in newly diagnosed pediatric CD patients. Further longitudinal investigations on a larger sample size will be necessary to confirm the present data and to search the immunological processes which could be the basis of the association between CD and SNHL.

First salivary screening of celiac disease by detection of anti-transglutaminase autoantibody radioimmunoassay in 5000 Italian primary schoolchildren

OBJECTIVE

The high prevalence of celiac disease (CD) prompted us to evaluate a new, noninvasive disease screening strategy. The aim was to identify CD in 6- to 8-year-old children for a timely diagnosis, start gluten-free diet (GFD) in compliant subjects, achieve the growth target, and prevent CD complications.

METHODS

Five thousand subjects were invited to participate in the study. Four thousand forty-eight saliva samples were tested for anti-tissue transglutaminase (tTG) immunoglobulin (Ig)A using a fluid-phase radioimmunoprecipitation method. Positive children were tested for serum radioimmunoassay tTG IgA, enzyme-linked immunosorbent assay tTG IgA, and anti-endomysium IgA. Children confirmed as positive by serum assays underwent endoscopy with duodenal biopsies and, at the diagnosis of CD, were suggested to start GFD.

RESULTS

Consent was obtained from 4242 parents (84.8%) for the screening to be performed, and adequate saliva samples were collected from 4048 children (95.4%). Thirty-two children were found to be salivary tTG IgA positive and 9 with borderline autoantibody levels. Thirty-one of the 32 and 3 of the 9 subjects were also serum positive. Twenty-eight children showed villous atrophy when undergoing intestinal biopsy, whereas 1 had Marsh 1 lesions; 3 children were suggested to start GFD without performing endoscopy. CD prevalence in the population investigated (including 19 CD known cases) was 1.16%. The ratio between screening-detected patients and those diagnosed before the screening was 3:2. The ratio between symptomatic and asymptomatic patients was 1:1.6.

CONCLUSIONS

We demonstrated that it is possible to perform a powerful, simple, well-accepted, and sensitive CD screening using saliva. Until now, the compliance with GFD in children with CD has been optimal.

Evolutionary and functional analysis of celiac risk loci reveals SH2B3 as a protective factor against bacterial infection

Celiac disease (CD) is an intolerance to dietary proteins of wheat, barley, and rye. CD may have substantial morbidity, yet it is quite common with a prevalence of 1%-2% in Western populations. It is not clear why the CD phenotype is so prevalent despite its negative effects on human health, especially because appropriate treatment in the form of a gluten-free diet has only been available since the 1950s, when dietary gluten was discovered to be the triggering factor. The high prevalence of CD might suggest that genes underlying this disease may have been favored by the process of natural selection. We assessed signatures of selection for ten confirmed CD-associated loci in several genome-wide data sets, comprising 8154 controls from four European populations and 195 individuals from a North African population, by studying haplotype lengths via the integrated haplotype score (iHS) method. Consistent signs of positive selection for CD-associated derived alleles were observed in three loci: IL12A, IL18RAP, and SH2B3. For the SH2B3 risk allele, we also show a difference in allele frequency distribution (Fst) between HapMap phase II populations. Functional investigation of the effect of the SH2B3 genotype in response to lipopolysaccharide and muramyl dipeptide revealed that carriers of the SH2B3 rs3184504*A risk allele showed stronger activation of the NOD2 recognition pathway. This suggests that SH2B3 plays a role in protection against bacteria infection, and it provides a possible explanation for the selective sweep on SH2B3, which occurred sometime between 1200 and 1700 years ago.

Coeliac disease does not affect visual acuity: a study of young men in the Swedish national conscripts register

OBJECTIVE. Coeliac disease (CD) is associated with neurological disease, but there are little data on visual acuity in CD. The objective of this study was to examine visual acuity in undiagnosed and diagnosed CD. MATERIAL AND METHODS. Visual acuity was evaluated in Swedish male conscripts: 69 with undiagnosed CD (diagnosed after the conscription), 996 with diagnosed CD (diagnosed before the conscription) and 6850 without a diagnosis of CD. Information on CD was obtained from the Swedish Inpatient Registry 1964-2003. Visual acuity was measured at conscription, and analyses were based on visual acuity test scores from 1983 to 2000 when conscription attendance rates were close to 100% among Swedish males. We defined the highest test score (9/9) as normal, and 0-8/9 as decreased visual acuity. RESULTS. The mean (+/-SD) visual acuity score was similar in all three groups: reference individuals, 8.03+/-1.46; undiagnosed CD, 8.04+/-1.37; diagnosed CD, 8.02+/-1.50 (median test score in all three groups was 8/9). The prevalence of decreased visual acuity (0-8/9) did not differ according to CD status (reference individuals: 35.3%; undiagnosed CD: 36.2%; diagnosed CD: 36.0%) (p=0.890). CONCLUSION. In young men, CD does not affect visual acuity.

Differential mucosal IL-17 expression in two gliadin-induced disorders: gluten sensitivity and the autoimmune enteropathy celiac disease

BACKGROUND

The immune-mediated enteropathy, celiac disease (CD), and gluten sensitivity (GS) are two distinct clinical conditions that are both triggered by the ingestion of wheat gliadin. CD, but not GS, is associated with and possibly mediated by an autoimmune process. Recent studies show that gliadin may induce the activation of IL-17-producing T cells and that IL-17 expression in the CD mucosa correlates with gluten intake.

METHODS

The small-intestinal mucosa of patients with CD and GS and dyspeptic controls was analyzed for expression of IL-17A mRNA by quantitative RT-PCR. The number of CD3+ and TCR-gammadelta lymphocytes and the proportion of CD3+ cells coexpressing the Th17 marker CCR6 were examined by in situ small-intestinal immunohistochemistry.

RESULTS

Mucosal expression of IL-17A was significantly increased in CD but not in GS patients, compared to controls. This difference was due to enhanced IL-17A levels in >50% of CD patients, with the remainder expressing levels similar to GS patients or controls, and was paralleled by a trend toward increased proportions of CD3+CCR6+ cells in intestinal mucosal specimens from these subjects.

CONCLUSION

We conclude that GS, albeit gluten-induced, is different from CD not only with respect to the genetic makeup and clinical and functional parameters, but also with respect to the nature of the immune response. Our findings also suggest that two subgroups of CD, IL-17-dependent and IL-17-independent, may be identified based on differential mucosal expression of this cytokine.

[Diarrhea, from the gastroenterologist's point of view]

Patients seeking help from gastroenterologist have frequent complaints of changes in the quality and quantity of stool as well in the frequency of bowel movements. Definition of diarrhea includes: more than three bowel movements daily, more than 200 grams of the stool daily, and its water content exceeding 75-85%. Diarrhea lowers the quality of life and can be a sign of organic disease. Its course can be acute and chronic. According to the pathomechanism, diarrheas can be divided into four different types: exudative (inflammatory), osmotic, dismotility and secretory. Acute diarrheas are usually infective, and sometimes they result in very serious conditions. Their course runs from a few days to a couple of weeks. If diarrhea persists more than four weeks, it is the chronic variant and it justifies gastroenterological examination. During the evaluation, we have to think of endocrine, autoimmune, allergic, postoperative states and the side effect of medications beside primer gastroenterological causes. To differentiate from a number of wide scale of clinical pictures and to reach the correct diagnosis, we are aided by the characteristics of diarrhea, the accompanying symptoms, laboratory values and invasive examinations. With the present summary, we would like to give a guide to the practicing physicians, mainly with a symptom-oriented approach.

A guide to diagnosis of iron deficiency and iron deficiency anemia in digestive diseases

Iron deficiency (ID), with or without anemia, is often caused by digestive diseases and should always be investigated, except in very specific situations, as its causes could be serious diseases, such as cancer. Diagnosis of ID is not always easy. Low serum levels of ferritin or transferrin saturation, imply a situation of absolute or functional ID. It is sometimes difficult to differentiate ID anemia from anemia of chronic diseases, which can coexist. In this case, other parameters, such as soluble transferrin receptor activity can be very useful. After an initial evaluation by clinical history, urine analysis, and serological tests for celiac disease, gastroscopy and colonoscopy are the key diagnostic tools for investigating the origin of ID, and will detect the most important and prevalent diseases. If both tests are normal and anemia is not severe, treatment with oral iron can be indicated, along with stopping any treatment with non-steroidal anti-inflammatory drugs. In the absence of response to oral iron, or if the anemia is severe or clinical suspicion of important disease persists, we must insist on diagnostic evaluation. Repeat endoscopic studies should be considered in many cases and if both still show normal results, investigating the small bowel must be considered. The main techniques in this case are capsule endoscopy, followed by enteroscopy.

A short review of malabsorption and anemia

Anemia is a frequent finding in most diseases which cause malabsorption. The most frequent etiology is the combination of iron and vitamin B12 deficiency. Celiac disease is frequently diagnosed in patients referred for evaluation of iron deficiency anemia (IDA), being reported in 1.8%-14.6% of patients. Therefore, duodenal biopsies should be taken during endoscopy if no obvious cause of iron deficiency (ID) can be found. Cobalamin deficiency occurs frequently among elderly patients, but it is often unrecognized because the clinical manifestations are subtle; it is caused primarily by food-cobalamin malabsorption and pernicious anemia. The classic treatment of cobalamin deficiency has been parenteral administration of the vitamin. Recent data suggest that alternative routes of cobalamin administration (oral and nasal) may be useful in some cases. Anemia is a frequent complication of gastrectomy, and has been often described after bariatric surgery. It has been shown that banding procedures which maintain digestive continuity with the antrum and duodenum are associated with low rates of ID. Helicobacter pylori (H pylori) infection may be considered as a risk factor for IDA, mainly in groups with high demands for iron, such as some children and adolescents. Further controlled trials are needed before making solid recommendations about H pylori eradication in these cases.