Coeliac disease hidden by cryptogenic hypertransaminasaemia

Rapid regression of psoriasis in a coeliac patient after gluten-free diet. A case report and review of the literature

BACKGROUND

Several skin disorders are present in patients affected by coeliac disease (CD) - among them, psoriasis has been described. However, at present the relationship between CD and psoriasis remains controversial since there are few and contrasting data on this topic.

METHOD

Here we describe a case of psoriasis in a CD patient not responding to specific therapies for psoriasis.

RESULT

The regression of skin lesions after gluten-free diet (GFD) was evident in a short time.

CONCLUSION

The present case supports the association between CD and psoriasis and the concept that psoriasis in CD patients can be improved by GFD. Future studies are needed to clarify the possible mechanisms involved in this association.

Liver abnormalities in celiac disease

Celiac disease is an intolerance of the small bowel to gluten. Although most symptomatic patients have symptoms related to the gastrointestinal tract, many extra-intestinal manifestations have been described. A wide spectrum of hepatobiliary diseases have been described, including asymptomatic elevations of liver enzyme levels, nonspecific hepatitis, nonalcoholic fatty liver disease, and autoimmune and cholestatic liver disease. In addition, celiac disease may be the underlying cause of unexplained elevations of liver enzyme levels. Because most patients do not have overt gastrointestinal symptoms, a high index of suspicion is required. Moreover, in the majority of patients, liver enzyme levels will normalize on a gluten-free diet. We review the literature pertaining to hepatic abnormalities that may be seen in association with celiac disease. We also suggest an approach to the investigation and management of these patients.

Advances in celiac disease

In recent years, it has become evident that CD is much more common than previously appreciated, with a prevalence of 0.5% to 1% in Western, Arabian, and Indian populations. The disease may be present without symptoms (silent CD) or may present with extraintestinal manifestations only. Increasing awareness of the many faces of CD will increase diagnosis rate. CD patients have a cure for their disease, named the gluten-free diet, but this curative measure is very hard to adhere to. With the new insights into the pathogenesis of CD, clinicians enter an era where new treatment modalities for CD may turn into reality.

Defining a proper setting for endoscopy in coeliac disease

OBJECTIVE

As it has been demonstrated that a careful duodenal inspection during upper gastrointestinal endoscopy may be useful in predicting coeliac disease, we tried to define the usefulness of endoscopy in detecting unsuspected coeliac patients.

DESIGN AND METHODS

We considered all the first diagnoses of coeliac disease from 1992 to 2001, i.e. 110 patients with a biopsy-proven diagnosis of coeliac disease. From 1992 to 1997, neither of the endoscopists paid careful attention to the endoscopic features of coeliac disease in the course of the examinations performed for indications other than coeliac disease. From 1998 to 2001, the same endoscopists looked very carefully at these endoscopic features, regardless of the indication for the procedure.

RESULTS

Over the first period, 22/16,081 patients endoscoped for the first time had a histological diagnosis of coeliac disease, with a prevalence of 1/731. In all 22 patients the indication for the examination was the suspicion of coeliac disease. The endoscopic appearance of the duodenum was indicative in 16/22 (72.7%) patients. Over the second period, the diagnosis of coeliac disease was made in 88/10,410 patients endoscoped for the first time. The prevalence of the disease was 1/118 examinations performed. The endoscopic appearance of the duodenum was indicative in 70/88 (79.5%) patients. In 13/88 patients, the diagnosis of coeliac disease was presumed because of the macroscopic appearance of duodenum, lacking a past history suggestive of coeliac disease.

CONCLUSIONS

Despite a still open controversy on the accuracy of endoscopic markers in the diagnosis of coeliac disease, we have found that in subjects not suspected for coeliac disease and undergoing an upper gastrointestinal endoscopy for other reasons, attention to the endoscopic pattern could facilitate the identification of a relevant number of cases.

Human recombinant anti-transglutaminase antibody testing is useful in the diagnosis of silent coeliac disease in a selected group of at-risk patients

BACKGROUND

Functional dyspepsia, unexplained chronic hypertransaminasaemia (CHT) and hepatitis C virus (HCV) are common gastrointestinal situations that have been related to coeliac disease. Antibodies to tissue transglutaminase (tTG) have been claimed recently to be highly effective as a screening method for coeliac disease.

AIM

To assess the prevalence of coeliac disease by means of detection of antibodies against human tTG in the above-mentioned groups of patients.

PATIENTS AND METHODS

A control group consisted of 165 normal blood donors. Patient groups comprised 90 CHT patients, 102 HCV patients and 92 functional dyspepsia patients. All patients were tested for anti-tTG (immunoglobulin A, IgA) antibodies. Anti-endomysium (IgA) antibodies (AEA) and antigliadin (IgA) antibodies (AGA) and antigliadin (immunoglobulin G, IgG) antibodies (AGG) were also tested. When anti-tTG or AEA was positive, a duodenal biopsy was recommended.

RESULTS

One of 165 blood donors, three of 92 functional dyspepsia patients, four of 90 CHT patients and none of 102 HCV patients were positive for anti-tTG antibodies. In the anti-tTG-positive group, all but one were AEA-positive. There were no AEA- or AGA IgA-positives that revealed a negative anti-tTG test. Duodenal biopsy confirmed a diagnosis of coeliac disease in all the cases. Statistically significant differences were found between the controls and the functional dyspepsia group and between the controls and the CHT group, but not between the controls and the HCV group.

CONCLUSIONS

Both CHT and functional dyspepsia may represent a true oligosymptomatic form of coeliac disease. In such conditions, the detection of anti-tTG antibodies is useful as a screening method. Coeliac disease is not an autoimmune manifestation of HCV, so screening for coeliac disease in HCV patients cannot be recommended.

Pancreatic hyperenzymaemia and hypertransaminasaemia in healthy subjects. Report of three cases

Three healthy subjects, two from Italy and one from the United States, showing a chronic increase in serum pancreatic enzymes and transaminases are described. The enzyme elevations reached very high levels but were not constant; rather, they fluctuated and sometimes returned to normal. Furthermore, tests for non-hepatic diseases that can be accompanied by an increase in serum transaminases, such as coeliac disease, were normal. The intervals between the first finding of the pancreatic hyperenzymaemia and the hypertransaminasaemia and this study ranged from 2 to 6 years (mean 4.3 years), during which the three subjects remained healthy, with no clinical, laboratory or imaging evidence of disease. These data support the conclusion that these increases in enzymes are benign; however, monitoring of these three subjects is already underway. Awareness of this anomaly is important, both to relieve the distress of the persons involved, as well as to avoid the numerous, sometimes invasive, complex and expensive examinations that might otherwise be unnecessarily performed.

Hypertransaminasemia in pediatric celiac disease patients and its prevalence as a diagnostic clue

OBJECTIVES

The aims of this study were to evaluate the following: 1) the prevalence of hypertransaminasemia (HT) in a pediatric celiac disease (CD) and its relation with clinical parameters; 2) the frequency of HT as the only manifestation of pediatric CD; and 3) the evolution of HT after a gluten free diet.

METHODS

A total of 114 consecutive pediatric CD patients were studied (60% with classical and 40% with atypical forms). Antiendomisyum antibodies and anti-tissue transglutaminase antibodies were determined in patients with a clinical suspicion of CD (including unexplained chronic HT), in patients at risk, and in patients with preoperative increased ALT activity for minor surgery. CD was confirmed by duodenal biopsy. At baseline, the relationship between clinical factors and aminotransferase status was univariately and multivariately assessed. After starting a gluten free diet, patients were followed up, until serological markers cleared and serum aminotransferase normalized.

RESULTS

HT occurred in 32% of patients (37 of 114) at diagnosis. HT was the only manifestation of CD in five patients (4.3%). Patients with HT were younger (2.9 +/- 0.4 yr) than patients with normal aminotransferases (5.1 +/- 0.5 yr) (p = 0.007). A higher percentage of patients with classical CD tend to have abnormal aminotransferases (73%; 95% CI = 65-81%) than do patients with atypical CD (27%; 95% CI = 19-35%) (p = 0.068). Logistic regression analysis showed that only younger age was significantly associated with HT (p = 0.039; OR = 0.8; 95% CI = 0.71-0.99). Aminotransferases normalized with a gluten free diet in all 35 patients who were followed-up, either before (n = 18) or at the same time (n = 17) as serological markers cleared.

CONCLUSIONS

HT is a frequent finding in pediatric CD patients and, in a substantial proportion, may be the only manifestation of CD. Thus, serological markers of CD should be introduced in the first step of the diagnostic workup of liver diseases in pediatric patients.

The liver in obesity and type 2 diabetes mellitus

Obesity and type 2 diabetes are associated strongly with NAFLD. It is not clear if one of these conditions causes the others, or if all are consequences of another process. Although NAFLD is known to occur in overly lean individuals, which indicates that excessive adiposity is not required for the development of NAFLD, the severities of insulin resistance and NAFLD tend to parallel each other, and the greatest prevalence of type 2 diabetes occurs in patients with NAFLD and cirrhosis. This observation suggests that insulin resistance and NAFLD may be related pathogenically. Experiments in mice demonstrate that insulin resistance and NAFLD result from a chronic inflammatory state that is characterized by increased levels of TNF alpha. The mechanisms that drive this chronic inflammation are unknown but might involve the oxidative stress that develops during fatty acid metabolism or when products from intestinal bacteria escape into the mesenteric blood to trigger a sustained hepatic inflammatory cytokine response in genetically susceptible individuals, promoting a positive feedback loop that reinforces insulin resistance and inflammation. This hypothesis is supported by some animal and human studies; however, more research is needed to evaluate this theory. Additional studies also are required to determine the benefits of treatments that interrupt this pathogenic cascade at various points. Preliminary work in animal and human studies suggests that diverse strategies that inhibit production of TNF alpha and improve insulin resistance also ameliorate NAFLD.

Coeliac disease and liver dysfunction

The spectrum and pathogenesis of liver dysfunction in coeliac disease (CD) is reviewed. CD and liver disease share common risk factors, and consequences of CD may cause liver dysfunction. Liver dysfunction should be sought in CD, and its aetiology explored when abnormalities persist after gluten exclusion. CD should be excluded in patients with unexplained liver dysfunction before being labelled "cryptogenic".

Coeliac disease

In the last few decades, the comprehension of epidemiological, pathogenic and clinical aspects of coeliac disease has increasingly improved. Serological screening studies on the general population have shown that the true coeliac disease prevalence in Europe is higher than previously reported. It has become clear that tissue transglutaminase has a crucial role in the pathogenesis of coeliac disease pathogenesis, and there is evidence that substitution of deamidated amino acidic residues at a critical position along the gliadin sequence dramatically increases immunological activation. The toxicity of many gluten epitopes has been investigated, so far, but recent studies have indicated the region 57-75 of alpha gliadin as a possible candidate epitope in the pathogenesis of coeliac disease. However, the wide heterogeneity of gliadin and glutenin molecules complicate any attempts to identify the toxic epitope, and the fascinating idea to produce detoxified grains will represent a great challenge in the near future. From a clinical point of view, there is now evidence of a broad spectrum of gluten conditions. Extra-intestinal signs, i.e., alopecia, unexplained neurological disorders, cryptic hypertransaminasaemia, increased red cell width, frequently constitute the only clinical manifestation at the diagnosis.

Celiac disease in patients with severe liver disease: gluten-free diet may reverse hepatic failure

BACKGROUND & AIMS

Mild liver abnormalities are common in patients with celiac disease and usually resolve with a gluten-free diet. We investigated the occurrence of celiac disease in patients with severe liver failure.

METHODS

Four patients with untreated celiac disease and severe liver disease are described. Further, the occurrence of celiac disease was studied in 185 adults with previous liver transplantation using serum immunoglobulin A endomysial and tissue transglutaminase antibodies in screening.

RESULTS

Of the 4 patients with severe liver disease and celiac disease, 1 had congenital liver fibrosis, 1 had massive hepatic steatosis, and 2 had progressive hepatitis without apparent origin. Three were even remitted for consideration of liver transplantation. Hepatic dysfunction reversed in all cases when a gluten-free diet was adopted. In the transplantation group, 8 patients (4.3%) had celiac disease. Six cases were detected before the operation: 3 had primary biliary cirrhosis, 1 had autoimmune hepatitis, 1 had primary sclerosing cholangitis, and 1 had congenital liver fibrosis. Only 1 patient had maintained a long-term strict gluten-free diet. Screening found 2 cases of celiac disease, 1 with autoimmune hepatitis and 1 with secondary sclerosing cholangitis.

CONCLUSIONS

The possible presence of celiac disease should be investigated in patients with severe liver disease. Dietary treatment may prevent progression to hepatic failure, even in cases in which liver transplantation is considered.

Are hepatitis G virus and TT virus involved in cryptogenic chronic liver disease?

BACKGROUND

Hepatitis G virus can cause chronic infection in man but the role of this agent in chronic liver disease is poorly understood. Little is known about the relation of another newly discovered agent, the TT virus, with chronic liver disease.

AIM

To investigate the rate of infection with hepatitis G virus and TT virus in patients with cryptogenic chronic liver disease.

PATIENTS

A total of 23 subjects with chronically raised alanine transaminase and a liver biopsy in whom all known causes of liver disease had been excluded, and 40 subjects with hepatitis C virus-related chronic liver disease.

METHODS

Evaluation of anti-hepatitis G virus by enzyme immunoassay. Hepatitis G virus-RNA by polymerase chain reaction with primers from the 5' NC and NS5a regions. TT virus-DNA by nested polymerase chain reaction with primers from the ORF1 region. Results. Hepatitis G virus-RNA was detected in 4 out of 23 patients with cryptogenic chronic hepatitis and in 6 out of 40 with hepatitis C virus chronic hepatitis (17.4% vs 15% p=ns). At least one marker of hepatitis G virus infection (hepatitis G virus-RNA and/or anti-hepatitis G virus, mostly mutually exclusive) was present in 6 out of 23 patients with cryptogenic hepatitis and 16 out of 40 with hepatitis C virus liver disease (26. 1% vs 40% p=ns). T virus-DNA was present in serum in 3 subjects, 1 with cryptogenic and 2 with hepatitis C virus-related chronic liver disease. Demographic and clinical features, including stage and grade of liver histology, were comparable between hepatitis G virus-infected and uninfected subjects. Severe liver damage [chronic hepatitis with fibrosis or cirrhosis) were significantly more frequent in subjects with hepatitis C virus liver disease.

CONCLUSIONS

In Southern Italy, hepatitis G virus infection is widespread among patients with chronic hepatitis, independently of parenteral risk factors. Its frequency in subjects with cryptogenic liver disease parallels that observed in hepatitis C virus chronic liver disease, thus ruling out an aetiologic role of hepatitis G virus. TT virus infection is uncommon in patients with cryptogenic or hepatitis C virus-related liver disease who do not have a history of parenteral exposure.

Diagnosis of celiac sprue

Celiac sprue is a common lifelong disorder affecting 0.3-1% of the Western world and causing considerable ill health and increased mortality, particularly from lymphoma and other malignancies. Although high prevalence rates have been reported in Western Europe, celiac sprue remains a rare diagnosis in North America. Whether celiac sprue is truly rare among North Americans or is simply underdiagnosed is unclear, although serological screening of healthy American blood donors suggests that a large number of American celiacs go undiagnosed. Celiac sprue is an elusive diagnosis, and often its only clue is the presence of iron or folate deficiency anemia or extraintestinal manifestations, such as osteoporosis, infertility, and neurological disturbances. The challenge for gastroenterologists and other physicians is to identify the large population of undiagnosed patients that probably exists in the community and offer them treatment with a gluten-free diet that will restore the great majority to full health and prevent the development of complications. The advent of highly sensitive and specific antiendomysium and tissue transglutaminase serological tests has modified our current approach to diagnosis and made fecal fat and D-xylose absorption testing obsolete. A single small bowel biopsy that demonstrates histological findings compatible with celiac sprue followed by a favorable clinical and serological response to gluten-free diet is now considered sufficient to definitely confirm the diagnosis. We review the wide spectrum of celiac sprue, its variable clinical manifestations, and the current approach to diagnosis.

Association of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling ROME II criteria referred to secondary care

BACKGROUND

Irritable bowel syndrome has a high prevalence. Consensus diagnostic criteria (ROME II) based on symptoms have been established to aid diagnosis. Although coeliac disease can be misdiagnosed as irritable bowel syndrome, no prospective study has been published in which patients with this disorder are investigated for coeliac disease. We aimed to assess the association of coeliac disease with irritable bowel syndrome in patients fulfilling ROME II criteria.

METHODS

We undertook a case-control study at a university hospital. 300 consecutive new patients who fulfilled Rome II criteria for irritable bowel syndrome, and 300 healthy controls (age and sex matched) were investigated for coeliac disease by analysis of serum IgA antigliadin, IgG antigliadin, and endomysial antibodies (EMA). Patients and controls with positive antibody results were offered duodenal biopsy to confirm the possibility of coeliac disease.

FINDINGS

66 patients with irritable bowel syndrome had positive antibody results, of whom 14 had coeliac disease (11 EMA positive, three EMA negative). Nine patients with positive antibody results were lost to follow-up or refused biopsy (only one EMA-positive patient refused biopsy), and 43 had normal duodenal mucosa. Two controls, both of whom were EMA positive, had coeliac disease. Compared with matched controls, irritable bowel syndrome was significantly associated with coeliac disease (p=0.004, odds ratio=7.0 [95% CI 1.7-28.0]).

INTERPRETATION

Patients with irritable bowel syndrome referred to secondary care should be investigated routinely for coeliac disease. With only EMA, three of 14 cases would have been missed.

Nodular regenerative hyperplasia of the liver in a patient with celiac disease

We present the case of dual adult celiac disease and liver disease with portal hypertension (esophageal varices); a percutaneous liver biopsy was compatible with nonspecific reactive hepatitis. Clinically, celiac disease was characterised by poor response to a gluten-free diet, with the development of a biochemical cholestasis and marked malnutrition. Our patient died of cerebral hemorrhage, at the age of 50 years, without associated risk factors. The necropsy demonstrated the existence of a nodular regenerative hyperplasia of the liver, splenic atrophy, gelatinous transformation of the bone marrow, and lymphocytic colitis. We discuss the different types of liver disorders associated with celiac disease and the possible relation between nodular regenerative hyperplasia and celiac disease, based on immunologic mechanisms.

Coeliac disease: the cause of the various associated disorders?

The advent of the endomysial antibody test has allowed the true association between coeliac disease and at least 12 other disorders to be established. There is evidence suggesting that coeliac disease is a cause of these disorders; a mechanism for this is proposed.

Prevalence and clinical picture of celiac disease in italian down syndrome patients: a multicenter study

BACKGROUND

A multicenter research study of Down syndrome patients was carried out to estimate the prevalence of celiac disease in patients with Down syndrome and to show clinical characteristics and laboratory data of Down syndrome patients.

METHODS

The authors studied 1,202 Down syndrome patients. Fifty-five celiac disease patients (group 1) were compared with 55 immunoglobulin A antigliadin-positive antiendomysium antibodies-negative patients (group 2) and with 57 immunoglobulin A antigliadin-negative antiendomysium antibodies-negative patients (group 3).

RESULTS

Celiac disease was diagnosed in 55 of 1,202 Down syndrome patients (4.6%). In group 1, weight and height percentiles were shifted to the left, whereas these parameters were normally distributed in groups 2 and 3. In celiac patients, diarrhea, vomiting, failure to thrive, anorexia, constipation, and abdominal distension were higher than in the other two groups. Low levels of hemoglobinemia, serum iron, and calcium were observed more frequently in group 1. The diagnosis of celiac disease was made after a mean period of 3.8 years from the initiation of symptoms. Sixty-nine percent of patients showed a classic presentation, 11% had atypical symptoms, and 20% had silent celiac disease. Autoimmune disorders were more frequent (30.9%) in group 1 than in the other two groups examined (15%; P < 0.05).

CONCLUSIONS

This study reconfirms a high prevalence of celiac disease in Down syndrome. However, the diagnostic delay, the detection of atypical symptoms or silent form in one third of the cases, and the increased incidence of autoimmune disorders suggest the need for the screening of celiac disease in all Down syndrome patients.

Anti tissue transglutaminase antibodies as predictors of silent coeliac disease in patients with hypertransaminasaemia of unknown origin

BACKGROUND

Unexplained hypertransaminasaemia can be regarded as an extraintestinal presentation of coeliac disease.

AIM

To evaluate the reliability of immunoglobulin A anti tissue transglutaminase antibodies for identifying coeliac disease in those patients with raised transaminases of unknown origin.

PATIENTS

Of 1,120 consecutive patients referred to the outpatient clinic for liver disease due to raised transaminases from September 1995 to December 1999, 110 were classified as having cryptogenic hypertransaminasaemia after the exclusion of every known cause of liver disease.

METHODS

These 110 patients were tested for immunoglobulin A anti tissue transglutaminase and antiendomysial antibodies by enzyme-linked immunosorbent assay and indirect immunofluorescence, respectively.

RESULTS

Ten patients resulted positive for both antibodies; in all of them duodenal biopsy showed a subtotal villous atrophy consistent with coeliac disease. They did not complain of any gastrointestinal symptom. Liver biopsy, performed in five, showed a histological picture of non-specific reactive hepatitis.

CONCLUSIONS

Due to the high proportion (9.15%) of patients with cryptogenic hypertransaminasaemia affected by symptomless coeliac disease, serological screening for gluten-sensitive enteropathy must be included in the work-up of these patients. In this respect, anti tissue transglutaminase antibodies represent a valid alternative to antiendomysial antibodies with the advantage of being feasible everywhere thanks to the worldwide availability of enzyme-linked immunosorbent assay.

Anxiety but not depression decreases in coeliac patients after one-year gluten-free diet: a longitudinal study

BACKGROUND

A high prevalence of anxiety and depression has been reported in untreated coeliac disease (CD) patients. At present, the role of a gluten-free diet (GFD) on psychological disorders is still poorly known. The aim of this study was to evaluate state and trait anxiety and depression in adult CD patients before and after 1 year of GFD.

METHODS

A total of 35 CD patients were studied before and after 1 year of GFD. A total of 59 healthy subjects matched for gender, age and socio-economic status were studied as a control group. State and trait anxiety were assessed with the STAI test; depression was assessed using the modified version of the SDS Zung self-rating depression scale (M-SDS). The tests were administered before (TO) and after 1 year of GFD (T1).

RESULTS

At T0, CD patients showed high levels of state anxiety in a significantly higher percentage compared to controls (71.4% versus 23.7%; P < 0.0001), while there was no significant difference in trait anxiety between groups (25.7% versus 15.2%; P:ns); the percentage of subjects with depression was significantly higher in the CD group than in the control group (57.1% versus 9.6%; P < 0.0001). At T1, a significant decrease in the percentage of state anxiety was found in CD patients (T0: 71.4% versus T1: 25.7%; P < 0.001), while there were no significant changes in the percentage of trait anxiety (T0: 25.7% versus T1: 17.1%; P:ns) or depression (T0: 57.1.% versus T1: 45.7%; P:ns), which was still present in a significantly higher percentage in treated CD compared to controls (P < 0.0001).

CONCLUSION

In CD patients anxiety is present in a predominantly reactive form and it decreases after GFD. Depression is present in a higher percentage in CD patients and 1 year of GFD fails significantly to affect depressive symptoms. The presence of depression after GFD could be related to the reduction in quality of life in CD patients. The non-regression of depression after GFD could suggest that these patients need psychological support.

Low prevalence of antigliadin and anti-endomysium antibodies in subclinical/silent celiac disease

OBJECTIVE

Endomysial antibodies (EMA) are a well-known hallmark of celiac disease, but some recent studies showed that the prevalence of these antibodies in clinical practice is lower than expected. The aim of our study was to determine the prevalence of antigliadin (AGA) and EMA antibodies on a consecutive series of subclinical/silent celiac patients.

METHODS

We studied 115 consecutive patients with subclinical (92 patients) or silent (23 patients) forms of celiac disease. AGA and EMA were screened in all patients. Histopathology of celiac disease was expressed according to the Marsh classification.

RESULTS

The overall AGA in subclinical form were positive in 77% (14 of 18) of patients with partial villous atrophy (VA), in 84% (21 of 25) of patients with subtotal VA, and in 90% (27 of 30) of patients with total VA, whereas EMA were positive in 88.88% (16 of 18) of patients with partial VA, in 92% (23 of 25) of patients with subtotal VA, and 96.66% (29 of 30) of patients with total VA. On the other hand, AGA were positive in 0% (zero of two) of patients with Marsh I and in 30% (three of 10) of patients with Marsh II, whereas EMA were positive in 0% (zero of two) of patients with Marsh I and in 40% (four of 10) of patients with Marsh II (Marsh I-IIIa vs Marsh IIIb-c, p = < 0.005 in overall AGA-positive patients and p = < 0.0001 in EMA-positive patients). At the same time the overall AGA in silent form were positive in 60% (three of five) of patients with partial VA, in 66.66% (four of six) of patients with subtotal VA, and in 77.77% (seven of nine) of patients with total VA, whereas EMA were positive in 80% (four of five) of patients with partial VA, in 83.33% (five of six) of patients with subtotal VA, and in 88.88% (eight of nine) of patients with total VA. On the other hand, overall AGA were positive in 0% of patients with both Marsh I (zero of one) and Marsh II (zero of two), as well as EMA were positive in 0% with both Marsh I (zero of one) and Marsh II (zero of two) (Marsh I-IIIa vs Marsh IIIb-c, p = < 0.001 in overall AGA-positive patients and p = < 0.007 in EMA-positive patients).

CONCLUSIONS

At this time small bowel biopsy seems to be the only correct procedure to diagnose a case of suspected celiac disease, especially in patients with mild symptoms or suspected for celiac disease, because they belong to high-risk groups.

Prevalence of silent coeliac disease in atopics

BACKGROUND

Coeliac disease sometimes runs a subclinical/silent course and is often associated with immunologic and non-immunologic diseases. Although atopy is described as one of the most frequently associated conditions, the prevalence of coeliac disease in atopics has not yet been established.

AIM

To evaluate the frequency of coeliac disease in an Italian series of atopics.

PATIENTS AND METHODS

Sera from 401 consecutive atopics with no clinical evidence of malabsorption were tested for IgA antiendomysial antibodies by indirect immunofluorescence on human umbilical cord and IgA anti tissue transglutaminase by enzyme-linked immunosorbent assay Results. Four patients (1%) were found to be positive for both autoantibodies. Intestinal biopsy confirmed the diagnosis of active coeliac disease. One of the 4 coeliacs was also affected by Down's syndrome, autoimmune thyroiditis and coeliac hepatitis. In another case, a previously unknown severe iron deficiency was detected.

CONCLUSIONS

The present study shows, for the first time, that the prevalence of coeliac disease in atopics is 1%, which is significantly higher than that in the general Italian population. Therefore, atopy should be considered a condition at risk and atopic patients routinely screened by means of specific autoantibody testing.

Clinical features of coeliac disease today

Coeliac disease is an inflammatory disorder of the small intestine induced by dietary gluten. This frequently results in malabsorption of a range of important nutrients including iron, folic acid, calcium and fat-soluble vitamins. Coeliac disease in now considered to be a common disorder, possibly affecting 1:300 of the general population. Many patients present in adulthood, have minimal symptoms, and gastrointestinal manifestations are frequently absent. The diagnosis and screening for coeliac disease has been dramatically facilitated by testing for endomysial autoantibodies, although biopsy and demonstration of a characteristic histological lesion remains the definitive diagnostic investigation. Treatment with a gluten-free diet is effective but requires good patient compliance and monitoring to succeed.

Autoantigen characterization in liver/kidney microsome positive hepatitis

Liver/kidney microsome autoantibodies are detectable in different forms of chronic hepatitis, namely autoimmune, viral, and drug-induced hepatitis and in hepatitis associated with Type 1 autoimmune polyglandular syndrome. Based on the aetiology of chronic hepatitis, liver/kidney microsome autoantibodies are directed against different enzymes with very little overlap. Thus, the simple Indirect Immunofluorescence test, which is universally used as a screening test to detect autoantibodies, does not allow subtyping of liver/kidney microsome autoantibodies. This brief review stresses the need to use methods such as Western-Blotting and enzyme-linked immunosorbent assay together with Indirect Immunofluorescence to characterize the liver/kidney microsome autoantibodies. Identification of the liver/kidney microsome target antigens, when possible, makes differential diagnosis easier and, at times, may help the clinician to choose the best approach to treatment.

Clinical features of celiac disease today

The clinical spectrum of celiac disease has widened over the past decades. The condition is no longer a severe malabsorption syndrome. Instead, a typical celiac disease patient today has merely mild abdominal symptoms. Malabsorption can be subclinical or absent, and there is usually only moderate, if any, loss of weight. Simultaneously, the current prevalence has increased from 1:1,000 to 1:300 inhabitants, or even higher. Clinically silent celiac disease cases are being detected in increasing numbers since the introduction and widespread use of serologic screening tests. Symptoms of celiac disease can appear outside the intestine, a typical example being dermatitis herpetiformis. Gluten intolerance is no longer limited to overt villous atrophy. Inflammation without villous damage may be observed in genetically susceptible individuals. The term latent celiac disease is applied in situations where the patient has normal villous architecture while on a gluten-containing diet, but later develops small bowel villous atrophy compatible with celiac disease.

Chronic unexplained hypertransaminasemia may be caused by occult celiac disease

In a subset of patients attending liver units, a chronic increase in serum transaminases may remain of undetermined cause despite thorough investigations. On the other hand, elevated levels of serum transaminases have been reported in about 40% of adult celiac patients. To evaluate the prevalence of subclinical celiac disease in patients with chronic unexplained hypertransaminasemia in comparison with that in the general population (0.5%), 140 consecutive patients with chronic increases of serum transaminases levels of unknown cause were tested for antigliadin and antiendomysium IgA antibodies. All patients with positive antibody tests were offered upper gastrointestinal endoscopy with distal duodenal biopsy. Thirteen patients (9.3%, 95% confidence interval 5. 0-15.4) had positive antigliadin and antiendomysium antibodies. The prevalence of antibodies was 17% in women and 5.4% in men (8/47 vs. 5/93 respectively; relative risk 3.2, 95% confidence interval 1.1-9. 1). Distal duodenal biopsy performed in all but one of the patients showed mild villous atrophy with increased intraepithelial lymphocytes in three cases, subtotal villous atrophy in six, and total villous atrophy in three. The prevalence of celiac disease in the patient group was significantly higher than that in the general population (P <.001) with a relative risk of 18.6 (95% confidence interval 11.1-31.2). On the basis of the present findings, screening for celiac disease is an important tool in the initial diagnostic work-up of patients with chronic unexplained hypertransaminasemia.

Celiac disease

There continues to be much research interest in celiac disease, with well over 200 papers published in the year under review, covering a multitude of areas from population screening to the molecular immunology of disease pathogenesis. The high prevalence of "silent" disease again has been demonstrated, and there is continued emphasis on the increasingly wide recognized range of associated conditions and extraintestinal manifestations. The case for the safety of oats is further strengthened by a study involving patients with dermatitis hepetiformis. One of the most significant scientific advances has been the discovery of a potential role for tissue transglutaminase, recently found to be the autoantigen of antiendomysial antibodies, in disease pathogenesis, by enhancing gliadin peptide class II binding and consequent T-cell activation. However, the very central role of T cells has been thrown into doubt with an elegant study that assessed the effect of blocking costimulation in T-cell activation.