The Oslo definitions for coeliac disease and related terms

ESPGHAN 'biopsy-sparing' guidelines for celiac disease in children with low antitransglutaminase during COVID-19

OBJECTIVES

Recent guidelines for celiac disease have allowed a biopsy-free approach in endomysial antibodies (EMAs) positive children with high antitransglutaminase (TGA-IgA) titer [>10 time upper limit of normal (ULN)]. Esophagogastroduodenoscopy is still necessary for diagnosis in children with lower title. Because elective pediatric endoscopy has been substantially shouted down during coronavirus disease (COVID-19) pandemic, many children remained undiagnosed - and therefore untreated - for a long time. We aimed to analyze the feasibility and accuracy of a biopsy-free approach in suspected celiac disease children with TGA-IgA values <10 ULN to facilitate the diagnostic process by avoiding endoscopy.

METHODS

In this study cohort, we retrospectively analyzed all biopsy-confirmed diagnosis of celiac disease in our center (between 2014 and 2019). The positive predictive value (PPV) of TGA-IgA titers between 5 and 10 ULN and positive EMA in diagnosing celiac disease were determined. Mucosal atrophy and resolution of symptoms after gluten-free diet (GFD) were considered to confirm initial diagnosis.

RESULTS

Of 430 celiac disease patients (F: 274; mean age 7.54 years) diagnosed by endoscopy, 84 (F: 46; mean age 8 years) with TGA-IgA between 5 and 10 ULN and positive EMA were identified. The PPV of TGA-IgA between 5 and 10 ULN and positive EMA was 0.93 (95% confidence interval 0.90-0.96). All these children had a symptom resolution and antibodies normalization after GFD.

CONCLUSION

During the COVID-19 outbreak, a temporarily reduction of the TGA-IgA threshold for biopsy-sparing approach seems feasible in EMA positive children with TGA-IgA between 5 and 10 ULN.

Role of the gut microbiota in the pathogenesis of coeliac disease and potential therapeutic implications

PURPOSE

Although genetic predisposition and exposure to dietary gluten are considered necessary triggers for the development of coeliac disease, alterations in the gut microbial composition may also contribute towards the pathogenesis of coeliac disease. This review aims to provide an overview of the available data on the potential mechanisms through which the gut microbiota plays a role in the causation of coeliac disease and to discuss the potential therapeutic strategies that could diminish the consequences of microbial dysbiosis.

METHOD

A search of the literature was performed using the PubMed, Embase, and JSTOR databases; relevant articles were included.

RESULTS

Recent studies in patients with coeliac disease have reported an increase in the relative amounts of gram negative bacterial genera such as Bacteroides, Prevotella, and Escherichia, and reduced amounts of protective anti-inflammatory bacteria such as Bifidobacteria and Lactobacilli. Dysbiotic microbiota may lead to a dysregulated immune response that may contribute to the pathogenesis of coeliac disease. In infancy, antibiotic use and certain infant feeding practices may lead to alterations in the developing gut microbiota to influence the immune maturation process and predispose to coeliac disease.

CONCLUSION

The induction of the intestinal immune system and gluten intolerance may be influenced by the relative abundance of certain microbiota. Factors such as infant feeding practices, diet, antibiotics, and infections, may be involved in the development of coeliac disease due to their influence on gut microbial composition. The efficacy of potential modulators of the gut microbiota such as probiotics, prebiotics, and fecal microbial transplant as adjunctive treatments to gluten-free diet in coeliac disease is unproven and requires further investigation.

Orthodontics in patients with significant medical co-morbidities

A wide variety of patients with medical co-morbidities may present to general orthodontic practice. It is important for the treating clinician to have a general understanding of key medical conditions that may impact upon the treatment and management options. This clinical supplement provides a treatment-focused summative update for the orthodontist regarding significant medical co-morbidities, their general prevalence and an exploration of potential impacts upon orthodontic treatment. This review also discusses the significance of key medications and provides suggestions for the safe provision of orthodontic treatment.

Disease-Causing Mutations and Rearrangements in Long Non-coding RNA Gene Loci

The classic understanding of molecular disease-mechanisms is largely based on protein-centric models. During the past decade however, genetic studies have identified numerous disease-loci in the human genome that do not encode proteins. Such non-coding DNA variants increasingly gain attention in diagnostics and personalized medicine. Of particular interest are long non-coding RNA (lncRNA) genes, which generate transcripts longer than 200 nucleotides that are not translated into proteins. While most of the estimated ~20,000 lncRNAs currently remain of unknown function, a growing number of genetic studies link lncRNA gene aberrations with the development of human diseases, including diabetes, AIDS, inflammatory bowel disease, or cancer. This suggests that the protein-centric view of human diseases does not capture the full complexity of molecular patho-mechanisms, with important consequences for molecular diagnostics and therapy. This review illustrates well-documented lncRNA gene aberrations causatively linked to human diseases and discusses potential lessons for molecular disease models, diagnostics, and therapy.

Patient factors influencing acute gluten reactions and cytokine release in treated coeliac disease

BACKGROUND

Patients with coeliac disease (CD) commonly report a variety of adverse symptoms to gluten, but descriptions of the symptomatic response in the literature may have been confounded by the presence of food components such as fermentable carbohydrates (FODMAPs) causing symptoms of irritable bowel syndrome independent of gluten. In recent unmasked and masked low FODMAP gluten challenge studies in small groups of treated CD patients, nausea and vomiting were shown to be the key symptoms associated with serum interleukin (IL)-2 release. Our objective was to utilise a large and diverse cohort of people with CD undertaking a standardised gluten food challenge to characterise the demographic, genetic and clinical factors influencing the severity and timing of acute gluten reactions and IL-2 production.

METHODS

A total of 295 adults treated for CD were observed for 6 h after an unmasked food challenge consisting of 10 g vital wheat gluten (low in FODMAPs) in 100 ml water. Assessments included patient-reported outcomes, serum IL-2 and adverse events. Responses were analysed according to patient characteristics, HLA-DQ genotype, duodenal histology and response to a second gluten challenge.

RESULTS

Peak symptom severity was at 3 h (median severity 5/10). Peak IL-2 was at 4 h (median 4 pg/ml, range undetectable to 1028 pg/ml). Older age, older age at diagnosis, HLA-DQ2.5 positivity and homozygosity for HLA-DQB1*02 were each significantly associated with IL-2 elevations after gluten. Patients positive for HLA-DQ2.5, DQ8, DQ2.2 or DQ7 showed elevated IL-2 after gluten. Patient factors were not significantly associated with severity of digestive symptoms, but symptoms were correlated to one another and serum IL-2. Gluten challenge after 5 months caused more vomiting and higher IL-2 levels, but responses correlated with the first.

CONCLUSIONS

Gluten-induced symptoms and cytokine release is common in adults with treated CD. Age, genetics and previous response to gluten predict these acute reactions to gluten challenge. Structured symptom assessment and serum IL-2 after standardised gluten challenge may inform on patient diagnosis, the role of gluten in symptomatology and the need for adjunctive treatment.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03644069 Registered 21 May 2018.

The Diverse Potential of Gluten from Different Durum Wheat Varieties in Triggering Celiac Disease: A Multilevel In Vitro, Ex Vivo and In Vivo Approach

The reasons behind the increasing prevalence of celiac disease (CD) worldwide are still not fully understood. This study adopted a multilevel approach (in vitro, ex vivo, in vivo) to assess the potential of gluten from different wheat varieties in triggering CD. Peptides triggering CD were identified and quantified in mixtures generated from simulated gastrointestinal digestion of wheat varieties (n = 82). Multivariate statistics enabled the discrimination of varieties generating low impact on CD (e.g., Saragolla) and high impact (e.g., Cappelli). Enrolled subjects (n = 46) were: 19 healthy subjects included in the control group; 27 celiac patients enrolled for the in vivo phase. Celiacs were divided into a gluten-free diet group (CD-GFD), and a GFD with Saragolla-based pasta group (CD-Sar). The diet was followed for 3 months. Data were compared between CD-Sar and CD-GFD before and after the experimental diet, demonstrating a limited ability of Saragolla to trigger immunity, although not comparable to a GFD. Ex vivo studies showed that Saragolla and Cappelli activated immune responses, although with great variability among patients. The diverse potential of durum wheat varieties in triggering CD immune response was demonstrated. Saragolla is not indicated for celiacs, yet it has a limited potential to trigger adverse immune response.

Is Peer Support in Group Clinics as Effective as Traditional Individual Appointments? The First Study in Patients With Celiac Disease

INTRODUCTION

Celiac disease (CD) is common, affecting approximately 1% of the population. The cornerstone of management is a gluten-free diet, with dietetic advice being the key to aiding implementation. The aim of the study was to assess group clinics in comparison with traditional individual appointments.

METHODS

Patients with a new diagnosis of CD, confirmed histologically, were prospectively recruited over 18 months in Sheffield, United Kingdom. Patients received either a group clinic or traditional one-to-one appointment, led by a dietitian. Quality-of-life questionnaires were completed at baseline, as well as biochemical parameters being recorded. Patients were followed up at 3 months, where adherence scores were assessed as well as biochemical parameters and quality of life questionnaires being completed.

RESULTS

Sixty patients with CD were prospectively recruited and received either an individual (n = 30) or group clinic (n = 30). A statistically significant reduction in tissue transglutaminase was noted following group clinics (mean 58.5, SD 43.4 U/mL vs mean 13.2, SD 5.7 U/mL, P < 0.01). No significant differences in baseline and follow-up biochemical parameters between one-to-one and group clinics were noted. At follow-up, there was no statistically significant difference between mean gluten-free diet adherence scores (mean 3.1, SD 0.4 vs mean 3.1, SD 0.7, P = 0.66) between one-to-one and group clinics.

DISCUSSION

This first study assessing group clinics in CD demonstrates they are as effective as traditional one-to-one clinics, with the added benefits of peer support and greater efficiency, with an estimated 54% reduction of dietetic resources.

Probiotic Potential and Gluten Hydrolysis Activity of Lactobacillus brevis KT16-2

Celiac disease (CD) is a chronic autoimmune disease that occurs in genetically predisposed individuals. Gluten-hydrolyzing probiotic bacteria are promising for alleviating symptoms in individuals with CD. Therefore, in this study, the gluten hydrolysis ability and probiotic potential of Lact. brevis KT16-2 were determined. Lact. brevis KT16-2 formed proteolysis zones on gluten and gliadin agar plates, in which gluten and gliadin were used as the only nitrogen sources. SDS-PAGE analysis showed that Lact. brevis KT16-2 completely hydrolyzed peptides ranging from 28 to 66 kDa in 8 h. Then, the survival of the strain in bile salts, in simulated gastric juice and at low pH was determined. Additionally, the antioxidant and antimicrobial substance production, autoaggregation, hydrophobicity and antibiotic resistance of the strain were investigated. API-ZYM test kits were used to determine the enzymatic capacity of the strain. Lact. brevis KT16-2 had the ability to hydrolyze wheat gluten. It was able to survive in a broad pH range (pH 2-8), in bile salts (0.3-1%), and in simulated gastric juice. It had the ability to autoaggregate (59.4%), and the hydrophobicity (52.7%) of the strain was determined. In addition, this strain was capable of producing antimicrobial peptides against test bacteria, including antibiotic-resistant bacteria. Cell-free supernatants (CFS) of the strain had high antioxidant activity (DPPH-71.0% and ABTS-54.1%). The results of this study suggest that Lact. brevis KT16-2, which can hydrolyze gliadin and has many essential probiotic properties, has the potential to be used as a probiotic supplement for individuals with CD.

Coeliac disease and noncoeliac wheat or gluten sensitivity

Coeliac disease (CD) and noncoeliac wheat or gluten sensitivity (NCWS/NCGS) are common gluten-related disorders. Both conditions can present with gastrointestinal and extraintestinal manifestations, which can be a challenge for physicians to discern between. Whilst coeliac serology and histological assessment are required for the diagnosis of CD, there are no clear biomarkers for the diagnosis of NCGS. The management of both conditions is with a gluten-free diet (GFD), although the duration, as well as strictness of adherence to a GFD in NCGS, is unclear. Adherence to a GFD in CD can also be challenging, with recent developments of noninvasive assessments, although histological assessment via duodenal biopsies remains the gold standard. The management of refractory coeliac disease remains particularly challenging, often requiring specialist input. Whilst wheat is noted to be a trigger for symptom generation in NCGS, it is unclear which components of wheat are responsible for symptom generation in this group, with further research required to elucidate the pathophysiology.

Low prevalence of upper endoscopic gastrointestinal findings despite high frequency of alarm symptoms at the time of diagnosis in adult coeliac disease

OBJECTIVES

Exclusion of organic disorders involving the upper gastrointestinal (UGI) is a mandatory step before considering a biopsy-avoidance diagnostic strategy for adult coeliac disease. We aim to evaluate the prevalence of alarm symptoms and coincidental UGI endoscopic findings at the time of diagnosis of coeliac disease. To develop consensus criteria to identify patients with coeliac disease requiring a gastroscopy and to evaluate whether alarm symptoms prompting gastroscopy were predictive of endoscopic findings.

METHODS

Presenting symptoms and UGI endoscopic findings at diagnosis of coeliac disease were collected retrospectively in 278 adult patients with coeliac disease diagnosed in Pavia between January 1999 and December 2017. A panel of experts developed criteria to evaluate which clinical scenarios warrant gastroscopy, which was then applied retrospectively to patients diagnosed in Pavia.

RESULTS

At least one alarm symptom was present in 177/278 patients, 121/278 met our criteria for gastroscopy. Major UGI endoscopic findings included 3 cases of autoimmune atrophic gastritis, 19 oesophagitis and 20 Helicobacter pylori infections. No organic disorders were found. Prevalence of major endoscopic findings did not differ between patients who met our criteria and those who did not.

CONCLUSIONS

Despite the high prevalence of alarm symptoms at diagnosis, coincident major UGI endoscopic findings are rare in adult coeliac disease. These results may be relevant for future developments in coeliac disease diagnosis in adults.

Healthcare Resource Utilization and Costs in Celiac Disease: A US Claims Analysis

INTRODUCTION

Celiac disease (CeD) is a lifelong immune-mediated enteropathy in which dietary gluten triggers an inflammatory reaction in the small intestine. This retrospective cohort study examines healthcare resource utilization (HRU) and costs between patients with CeD and matched controls.

METHODS

Patients with CeD (cases) with an endoscopic biopsy and ≥2 medical encounters with a CeD diagnosis between January 1, 2010, and October 1, 2015, were identified in the MarketScan databases. The date of the first claim with a CeD diagnosis on or after the endoscopic biopsy was the index date. Cases were matched 1:1 to patients without CeD (controls) on demographic characteristics and Deyo-Charlson Comorbidity Index score. Clinical characteristics, all-cause, and CeD-related HRU and costs (adjusted to 2017 US dollars) were compared between cases and controls during the 12 months before (baseline) and 24 months after (follow-up) the index date.

RESULTS

A total of 11,008 cases (mean age 40.6 years, 71.3% women) were matched to 11,008 controls. During the follow-up, a higher proportion of cases had all-cause and CeD-related HRU including inpatient admissions, emergency department visits, gastroenterologist visits, dietician visits, endoscopic biopsies, and gastroenterology imaging (all P ≤ 0.002). Incremental all-cause and CeD-related costs were in the first ($7,921 and $2,894) and second ($3,777 and $935) year of follow-up, driven by outpatient services costs.

DISCUSSION

In this US national claims database analysis, there was evidence of an increase in both all-cause and CeD-related HRU and related costs in patients with CeD compared with matched patients without CeD, suggesting a significant economic burden associated with CeD.

The Two Faces of Wheat

Wheat-based foods have been staple foods since about 10,000 years and constitute a major source of energy, dietary fiber, and micronutrients for the world population. The role of wheat in our diet, however, has recently been scrutinized by pseudoscientific books and media reports promoting the overall impression that wheat consumption makes people sick, stupid, fat, and addicted. Consequently, numerous consumers in Western countries have started to question their dietary habits related to wheat consumption and voluntarily decided to adopt a wheat-free diet without a medical diagnosis of any wheat-related disorder (WRD), such as celiac disease, wheat allergy, or non-celiac gluten sensitivity. The aim of this review is to achieve an objective judgment of the positive aspects of wheat consumption as well as adverse effects for individuals suffering from WRDs. The first part presents wheat constituents and their positive nutritional value, in particular, the consumption of products from whole-grain flours. The second part is focused on WRDs that affect predisposed individuals and can be treated with a gluten-free or -reduced diet. Based on all available scientific knowledge, wheat consumption is safe and healthy for the vast majority of people. There is no scientific evidence to support that the general population would benefit from a wheat-free diet.

Celiac Disease and Pregnancy Outcomes in Patients with Gestational Diabetes Mellitus

AIM

Gestational diabetes mellitus (GDM) and celiac disease, if not diagnosed and properly treated, are associated with adverse outcomes of pregnancy. The aim of our study was to examine pregnancies complicated by GDM in celiac and nonceliac women in terms of their metabolic parameters and maternal and fetal outcomes.

METHODS

The study involved 60 women with GDM, 20 with and 40 without celiac disease. Maternal clinical and metabolic parameters (glucose and insulin levels in the oral glucose tolerance test (OGTT), fasting plasma glucose, HbA1c, lipid profile, prepregnancy BMI, gestational weight gain, and chronic diseases), pregnancy outcomes (gestational hypertension, pre-eclampsia, eclampsia, time, and mode of delivery), and fetal parameters (weight and length at birth, and neonatal complications) were recorded.

RESULTS

The two groups did not differ significantly in maternal parameters other than blood glucose levels at 120' in the diagnostic OGTT (141.2 ± 35.2 vs 161.2 ± 35.4, mg/dl, p=0.047), prepartum cLDL (127.2 ± 43.5 vs 179.6 ± 31.7 mg/dl, p ≤ 0.001), and total cholesterol (229.0 ± 45.9 vs 292.5 ± 42.1 mg/dl, p ≤ 0.001), which were significantly lower in celiac women than in nonceliac controls. Children born from celiac women had a significantly higher birth weight (3458.1 ± 409.8 vs 3209.0 ± 432.7 g, p=0.044) and ponderal index (2.89 ± 0.32 vs 2.66 ± 0.25 g/cm3, p=0.006) and were more likely to be large for gestational age (27.8% vs 2.5%, p=0.012). Analyzing the composition of the celiac and nonceliac women's diet showed that, for the same amount of kilocalories, the gluten-free diet was associated with a slight increase in the amount of carbohydrates (49.75% vs 48.54%) and a reduction in the amount of protein (21.10% vs 23.31%) and especially of fiber (9.84% vs 12.71%).

CONCLUSIONS

Celiac women with GDM have much the same pregnancy outcomes as nonceliac women with GDM, except for fetal overgrowth. Gluten-free food, being richer in carbohydrates and less rich in fiber and protein, could have a role in fetal growth in celiac women.

Deregulation of miRNAs-cMYC circuits is a key event in refractory celiac disease type-2 lymphomagenesis

A percentage of celiac disease (CD) patients develop refractory type-2 disease (RCD2), a condition associated with increased risk of enteropathy-associated T-cell-lymphoma (EATL) and without therapeutic option. Therefore, we profiled the miRNome in series of peripheral T-cell lymphomas (PTCLs), CD, RCD1 or 2 and in the murine interleukin-15 (IL15)-transgenic (TG) model of RCD. The transcriptome was analyzed in 18 intestinal T-cell lymphomas (ITLs). Bioinformatics pipelines provided significant microRNA (miRNA) lists and predicted targets that were confirmed in a second set of patients. Our data show that ITLs have a unique miRNA profile with respect to other PTCLs. The c-MYC regulated miR-17/92 cluster distinguishes monomorphic epitheliotropic ITL (MEITL) from EATL and prognosticates EATL outcome. These miRNAs are decreased in IL15-TG mice upon Janus kinase (JAK) inhibition. The random forest algorithm identified a signature of 38 classifier miRNAs, among which, the miR-200 and miR-192/215 families were progressively lost in RCD2 and ITL-CD, whereas miR-17/92 and C19MC miRNAs were up-regulated. Accordingly, SMAD3, MDM2, c-Myc and activated-STAT3 were increased in RCD2 and EATL tissues while JAK inhibition in IL15-TG mice restored their levels to baseline. Our data suggest that miRNAs circuit supports activation of STAT3 and c-Myc oncogenic signaling in RCD2, thus contributing to lymphomagenesis. This novel understanding might pave the way to personalized medicine approaches for RCD and EATL.

Concurrent cerebral arterial and venous sinus thrombosis revealing celiac disease- a case report and literature review

Background

Celiac disease is an autoimmune condition characterized by an inappropriate immune reaction against gluten. It classically presents as chronic diarrhea, bloating, and nausea in addition to malabsorption symptoms such as weight loss and micronutrient deficiency. We report the first case of coinciding cerebral infarction and venous sinus thrombosis unveiling the diagnosis of celiac disease.

Case presentation

A 40-year old female patient with a four-day history of severe diarrhea presented with right hemiplegia and altered mental status. Imaging revealed left middle cerebral artery occlusion and left transverse and sigmoid venous sinus thrombosis, along with left jugular vein thrombosis. Her laboratory evaluation was notable for profound iron deficiency anemia, thrombocytosis, and hyperhomocysteinemia. Her positive anti-tissue transglutaminase IgA antibodies and ensuing duodenal biopsy confirmed the diagnosis of celiac disease.

Conclusions

Celiac disease has a wide range of intestinal and extraintestinal manifestations and can present with thrombotic events in young patients with iron deficiency and hyperhomocysteinemia.

Accuracy of potential diagnostic indicators for coeliac disease: a systematic review protocol

INTRODUCTION

Coeliac disease (CD) is a systemic immune-mediated disorder triggered by gluten in genetically predisposed individuals. CD is diagnosed using a combination of serology tests and endoscopic biopsy of the small intestine. However, because of non-specific symptoms and heterogeneous clinical presentation, diagnosing CD is challenging. Early detection of CD through improved case-finding strategies can improve the response to a gluten-free diet, patients' quality of life and potentially reduce the risk of complications. However, there is a lack of consensus in which groups may benefit from active case-finding.

METHODS AND ANALYSIS

We will perform a systematic review to determine the accuracy of diagnostic indicators (such as symptoms and risk factors) for CD in adults and children, and thus can help identify patients who should be offered CD testing. MEDLINE, Embase, Cochrane Library and Web of Science will be searched from 1997 until 2020. Screening will be performed in duplicate. Data extraction will be performed by one and checked by a second reviewer. Disagreements will be resolved through discussion or referral to a third reviewer. We will produce a narrative summary of identified prediction models. Studies, where 2×2 data can be extracted or reconstructed, will be treated as diagnostic accuracy studies, that is, the diagnostic indicators are the index tests and CD serology and/or biopsy is the reference standard. For each diagnostic indicator, we will perform a bivariate random-effects meta-analysis of the sensitivity and specificity.

ETHICS AND DISSEMINATION

Results will be reported in peer-reviewed journals, academic and public presentations and social media. We will convene an implementation panel to advise on the optimum strategy for enhanced dissemination. We will discuss findings with Coeliac UK to help with dissemination to patients. Ethical approval is not applicable, as this is a systematic review and no research participants will be involved.

PROSPERO REGISTRATION NUMBER

CRD42020170766.

The Prevalence of Celiac Disease in a Fracture Liaison Service Population

Celiac disease (CD) is a known risk factor for osteoporosis and fractures. The prevalence of CD in patients with a recent fracture is unknown. We therefore systematically screened patients at a fracture liaison service (FLS) to study the prevalence of CD. Patients with a recent fracture aged ≥ 50 years were invited to VieCuri Medical Center's FLS. In FLS attendees, bone mineral density (BMD) and laboratory evaluation for metabolic bone disorders and serological screening for CD was systematically evaluated. If serologic testing for CD was positive, duodenal biopsies were performed to confirm the diagnosis CD. Data were collected in 1042 consecutive FLS attendees. Median age was 66 years (Interquartile range (IQR) 15), 27.6% had a major and 6.9% a hip fracture, 26.4% had osteoporosis and 50.8% osteopenia. Prevalent vertebral fractures were found in 29.1%. CD was already diagnosed in two patients (0.19%), one still had a positive serology. Three other patients (0.29%) had a positive serology for CD (one with gastro-intestinal complaints). In two of them, CD was confirmed by duodenal histology (0.19%) and one refused further evaluation. The prevalence of biopsy-proven CD was therefore 0.38% (4/1042) of which 0.19% (2/1042) was newly diagnosed. The prevalence of CD in patients with a recent fracture at the FLS was 0.38% and within the range of reported prevalences in the Western-European population (0.33-1.5%). Newly diagnosed CD was only found in 0.19%. Therefore, standard screening for CD in FLS patients is not recommended.

Factors associated with non adherence to a gluten free diet in adult with celiac disease: A survey assessed by BIAGI score

INTRODUCTION

The cornerstone of the recommended treatment for Celiac disease (CeD) is a lifelong strict gluten-free diet (GFD). We aimed to identify prospectively the demographic, clinical, social and psychological profile associated with non-adherence to a GFD in adult CeD patients in Israel.

METHODS

An anonymous online questionnaire was sent via the Israeli Celiac association and through social networks. Only CeD patients≥18 years old were included. Socio-demographic, laboratory and clinical data as well as anxiety and depression scores were reported. Adherence to a GFD was assessed by a Biagi questionnaire.

RESULTS

In total, 301 patients completed the questionnaire with a mean age of 37.5±14.9 years, 79.2% female. The most common presenting symptoms were: anemia (59.7%), abdominal pain (50.8%) and diarrhea (42.8%). According to the Biagi score, 82% of patients were found to be high adherent to a GFD (Biagi 3-4) and 18% were low adherent to a GFD (Biagi-0-2). Univariate analysis revealed that low adherence was associated with: younger age at the time of diagnosis (P<0.001), longer duration of disease (P=0.011) non academic education (P=0.011), below average income (P=0.018), smoking (P<0.001) and no gastroenterology follow up (P=0.038). However, in multivariate analysis, only a young age at diagnosis and smoking were significantly associated with non-adherence to a GFD (OR 0.924, 3.48, P-value<0.001, 0.029, respectively). In further analysis, we identified that age 20 is the best cutoff value to discriminate between those with high adherence and those with low adherence.

CONCLUSIONS

Young age, smoking, long disease duration, no academic education, low income and no gastroenterology follow-up were found to be associated with low adherence to GFD rate in a univariate analysis, however only the first two were found to be significant in the multivariate analysis. Additional intervention strategies might improve adherence and reduce future complications with a better quality of life.

Novel Therapeutic Strategies for Celiac Disease

Celiac disease (CeD) is a widespread autoimmune enteropathy caused by dietary gluten peptides in genetically susceptible individuals, which includes a range of intestinal and extraintestinal manifestations. Currently, there is no effective treatment for CeD other than strict adherence to a gluten-free diet (GFD). However, persistent or frequent symptoms and also partial villus atrophy were observed in some patients with CeD due to intentional or inadvertent gluten exposure during the use of GFD. It means that GFD alone is not enough to control CeD symptoms and long-term complications. Accordingly, new therapeutic approaches for CeD treatment such as gluten proteolysis, removing gluten from the digestive tract, promoting tight junction assembly, inhibiting intestinal tissue transglutaminase 2, using probiotics, and developing immunotherapeutic methods have been proposed through different strategies. This review focused on discussing the novel therapeutic strategies for CeD management.

Marked coagulopathy without liver disease or anticoagulation therapy

Symptomatic coagulopathies in celiac disease (CD) are rare. Here, we report a profound case of coagulopathy in a celiac. A 66-year old female without liver disease or anti-coagulation therapy presented with multiple ecchymoses, guaiac positive melanic stool, and a recent 4.5kg weight loss. Laboratory values included hemoglobin, 3.8g/dL; MCV, 66 fL; serum iron, 17μg/dL; platelet count, 580K/μL; white count, 14.2K/μL, and vitamin D,<5.0ng/mL. Additional values included partial thromboplastin time (PTT), >200s; prothrombin time (PT), >150s; INR, 20.5, putting her at extreme risk of bleeding. Vitamin K deficiency was assumed. The patient was given two units of fresh frozen plasma, packed red cells, and vitamin K intravenously. Endoscopy and biopsies demonstrated duodenal mucosal atrophy with cobblestoning, erosive gastritis, flattened duodenal villi and numerous intraepithelial lymphocytes. Transglutaminase serology demonstrated IgA TTG>100 U/mL (normal<3U/mL), confirming a diagnosis of CD. The patient's coagulopathy resolved within two days following admission. This case underscores the importance of CD testing in all patients with coagulopathies of unknown origin. Although coagulopathy is an uncommon presentation of CD, in extreme cases such as this, it has the potential to be life-threatening.

Gluten consumption may contribute to worldwide obesity prevalence

Gluten consumption has been controversially associated with obesity in previous studies. We sought to examine this association at the worldwide level.

Country specific data were obtained from 168 countries. Scatter plots, bivariate, partial correlation and multiple linear regression models were used to explore and compare the coincidence between obesity prevalence and consumption of gluten, non-gluten cereal protein and total cereal protein respectively. The established risk factors of obesity: caloric intake, sedentary lifestyle, urbanization, socioeconomic status, meat protein intake and sugar consumption were included in analyses as potential confounders. The 168 countries were also stratified into developing and developed country groupings for further examination of the relationships.

Worldwide, bivariate correlation analyses revealed that the strength and direction of correlations between all variables (independent, dependent and potential confounders) were at similar levels. Obesity prevalence was positively correlated to gluten consumption but was negatively correlated to consumption of non-gluten cereal protein, and was in almost nil correlation to total cereal protein consumption. These relationships were similar across all countries (n= 168), developed country grouping (N=44) and developing country grouping (n=124). When caloric intake, Gross Domestic Product at Purchasing Power Parity, sedentary lifestyle and urbanization were kept statistically constant in the partial correlation analysis, obesity was significantly correlated to gluten consumption in all countries, developed country grouping and developing country grouping, and was significantly but inversely and weakly correlated to non-gluten cereal protein in all countries and developing countries, and was in almost nil correlation to total cereal protein in all country groupings. Globally, stepwise multiple regression analysis, when all the independent variables and potential confounding factors were included, selected consumption of sugar as the variable having the greatest influence on obesity with R2 = 0.510, while gluten was placed second increasing R2 to 0.596. Gluten consumption may have been emerging as an inconspicuous, but significant cause of obesity. While Westernization has driven the diet patterns worldwide to incorporate more gluten crops, obesity prevalence projection methods may estimate future obesity rates poorly if gluten consumption is not considered.

Quality-of-Life Evaluation in Coeliac Patients on a Gluten-Free Diet

The treatment for coeliac disease (CD) has a considerable psychological impact on patients, which may vary depending on subjects and clinical characteristics. The aim of this study was to describe the quality of life (QoL) in CD patients during follow-up, evaluating which factors can influence it. Patients with CD who consecutively visited the outpatient clinic of CD Unit of the University Hospital of Padua from January to September 2019 were enrolled. Demographics and clinical information were collected, and all patients were asked to answer the CD-QoL and Biagi’s validated questionnaires. Student’s t-test and chi-square test were used to compare the continuous and categorical variables, respectively. One hundred patients were enrolled (86 females, mean age at test ± SD: 39.73 ± 13.51; mean age at diagnosis ± SD: 33.09 ± 12.92), with 61% of them having been diagnosed with CD within the previous 5 years. At the time of diagnosis, 43 CD patients reported classical CD presentation, 32 non-classical features, 16 only anaemia and 9 were asymptomatic. The mean CD-QoL value was overall high (80.54 ± 11.91). We found that the “health concerns” subscale score was significantly lower in subjects aged more than 35 years compared to younger subjects (p = 0.03). We also observed that the CD-QoL score in gluten-free diet (GFD)-adherent patients tended to be higher compared to subjects who were non-compliant, with a significantly higher percentage of patients with low score for the “dysphoria” subscale (p = 0.05). This study showed an overall good QoL in subjects on a GFD. However, subjects older and non-compliant to GFD appear to experience more health concerns and suffer from dysphoria, respectively.

Celiac disease and bone health: is there a gap in the management of postmenopausal osteoporosis?

Malabsorption due to celiac disease (CD) may contribute to postmenopausal osteoporosis. This study aimed to survey participants with CD regarding their bone density, fractures, and bone-preserving medications; to compare tolerance of bone-preserving medications in participants with and without CD; and to review the evidence for CD screening and osteoporosis therapies in the setting of CD. We recruited 131 participants with CD and 102 participants without CD. Of those with CD, 87% were diagnosed in adulthood and 40% had no recognized gastrointestinal symptoms. In 21% CD was diagnosed after the diagnosis of osteoporosis and in 9% after a fracture. No difference was found in the tolerability of bone medications between participants with CD and those without. Review of the literature found that, although monitoring of bone health is recommended for patients with CD, screening for CD is not generally accepted for patients with osteoporosis, although studies of the prevalence of CD in osteoporosis had incomplete ascertainment methods. There is a lack of well-conducted studies and therefore insufficient data for the efficacy and tolerability of bone medication in CD. In conclusion, both CD and menopause lead to bone loss. Identifying CD in postmenopausal women should lead to modification of osteoporosis management.

Testing for fecal gluten immunogenic peptides: a useful tool to evaluate compliance with gluten-free diet by celiacs

Background

Although experts agree that strict dietary compliance is fundamental for the health of celiac patients, there are no evidence-based recommendations on the best way to assess dietary compliance. Detection of gluten immunogenic peptides (GIPs) in feces was recently proposed as an effective method of assessing the dietary compliance of celiac patients.

Methods

Fifty-five consecutive celiac patients (27 adults and 28 children, age 6-72 years), who had been on a gluten-free diet for at least 2 years, were enrolled. All patients were evaluated clinically for symptoms, physical parameters and laboratory parameters. Dietary compliance was assessed with the Biagi questionnaire and serum anti-tissue transglutaminase (tTG) IgA antibodies were measured. GIPs were determined by immunoenzymatic assay on an automated Chorus analyzer (DIESSE Diagnostica Senese), after extraction of fecal samples by the method developed by DIESSE.

Results

Eight patients tested positive for GIPs (GIPs+); 71.4% of GIP-positive patients were asymptomatic; tTG antibodies were detected in 3/8 GIP+ patients. The Biagi score was significantly associated with fecal positivity for GIPs (P=0.02). However, according to the Biagi score, 57.1% of GIP+ patients followed the diet strictly and 5.4% of GIP- subjects did not comply with the diet or made substantial mistakes.

Conclusions

Assay of fecal GIPs identified more patients who did not comply with the diet than did the Biagi questionnaire, evaluation of symptoms or anti-tTG antibodies. Detection of fecal GIPs offers a direct, objective, quantitative assessment of even occasional exposure to gluten and is confirmed as a practical way to check dietary compliance.

American Registry of Pathology Expert Opinions: Recommendations for the diagnostic workup of mature T cell neoplasms

The diagnosis of T-cell lymphomas is highly challenging and requires an integrated approach in which clinical, morphologic, immunophenotypic and molecular data are incorporated into the diagnosis. Under the auspices of the American Registry of Pathology, the authors met to discuss this topic with the goal to provide practical and useful recommendations for pathologists when evaluating T-cell lymphomas. In this review, we discuss the diagnostic findings and workup for the various types of nodal T-cell lymphoma including anaplastic large cell lymphoma, nodal peripheral T-cell lymphoma not otherwise specified (PTCL-NOS), and PTCL with a T follicular helper (TFH) phenotype. We review clinicopathologic and immunophenotypic features (including flow cytometry panels) helpful in the differential diagnosis of mature T-cell lymphomas presenting in the peripheral blood and bone marrow, and we discuss some of the more common extranodal-based T-cell lymphomas including extranodal natural killer/T-cell lymphoma of nasal and non-nasal type, gamma delta T cell lymphomas, and aggressive and indolent T- and NK-lymphoproliferative disorders involving the gastrointestinal tract. Mycosis fungoides and most other cutaneous T-cell lymphomas are not the focus of this review, although the differential diagnosis of Sezary syndrome from mycosis fungoides is covered. We do not intend for these recommendations to be anything other than suggestions that will hopefully spur on additional discussion, and perhaps eventually evolve into a consensus approach for the workup of T-cell lymphomas.

A Gluten Free Diet in the Management of Epilepsy in People with Coeliac Disease or Gluten Sensitivity

The aim of this review was to assess the effects of a gluten free diet (GFD) in the management of epilepsy in people with coeliac disease (CD) or gluten sensitivity (GS). A systematic approach was used to undertake a literature review. Five electronic databases (PubMed; Scopus; Google Scholar; Cochrane Epilepsy Group specialised register; Cochrane Register of Controlled Trails (CENTRAL) via the Cochrane Register of Online Trials) were searched using predetermined relevant search terms. In total, 668 articles were identified. Duplicates were removed and predefined inclusion and exclusion criteria were applied, and a PRISMA flow chart was produced. Data was extracted using Covidence software. Twelve studies on Epilepsy and CD involving a total of 70 participants were selected for analysis; narrative synthesis was used owing to the small sample sizes in the selected studies. None of the 12 studies meeting inclusion criteria investigated gluten sensitivity and epilepsy. All the included studies support a link between epilepsy and CD. GFD was effective in 44 out of 70 participants across the studies in terms of a reduction of seizures, reduction of antiepileptic drugs (AEDs) or normalisation of EEG pattern. A total of 44 participants showed a reduction in seizures (across eight studies) and complete cessation of seizures was reported in 22 participants. In general, the earlier the GFD is implemented after the onset of seizures, the better the likelihood of the GFD being successful in supporting control of seizures. Mechanisms linking gluten with epilepsy are not fully understood; possible hypotheses include gluten mediated toxicity, immune-induced cortical damage and malabsorption. Evidence suggests the effectiveness of a GFD in supporting the management of epilepsy in patients with CD, although the quality of evidence is low. There appears to be a growing number of neurologists who are prepared to advocate the use of a GFD. A multidisciplinary approaches and further research are recommended. It could be argued that when balancing potential treatments such as AEDs or surgery, a GFD has a low likelihood of harm.

PARK7 Diminishes Oxidative Stress-Induced Mucosal Damage in Celiac Disease

Coeliac disease (CD) is a chronic, immune-mediated small intestinal enteropathy, accompanied with gluten-triggered oxidative damage of duodenal mucosa. Previously, our research group reported an increased mucosal level of the antioxidant protein Parkinson's disease 7 (PARK7) in children with CD. In the present study, we investigated the role of increased PARK7 level on the epithelial cell and mucosal integrity of the small intestine. The presence of PARK7 was investigated using immunofluorescent staining on duodenal mucosa of children with CD and on FHs74Int duodenal epithelial cells. To investigate the role of oxidative stress, FHs74Int cells were treated with H2O2 in the absence or presence of Comp23, a PARK7-binding compound. Intracellular accumulation of reactive oxygen species (ROS) was determined by DCFDA-based assay. Cell viability was measured by MTT, LDH, and Annexin V apoptosis assays. Disruption of cytoskeleton and cell adhesion was investigated by immunofluorescence staining and by real-time RT PCR. Effect of PARK7 on mucosal permeability was investigated ex vivo using intestinal sacs derived from control and Comp-23-pretreated mice. Comp23 treatment reduced the H2O2-induced intracellular accumulation of ROS, thus preserving the integrity of the cytoskeleton and also the viability of the FHs74Int cells. Accordingly, Comp23 treatment increased the expression of antioxidants (NRF2, TRX1, GCLC, HMOX1, NQO1), cell-cycle regulators (TP53, CDKN1A, PCNA, BCL2, BAX), and cell adhesion molecules (ZO1, CDH1, VCL, ITGB5) of H2O2-treated cells. Pretreatment with Comp23 considerably decreased the small intestinal permeability. In this study, we demonstrate that PARK7-binding Comp23 reduces the oxidative damage of duodenal epithelial cells, via increased expression of NRF2- and P53-regulated genes. Our results suggest that PARK7 plays a significant role in the maintenance of mucosal integrity in CD.

[Diagnosis of celiac disease in clinical practice: present and future]

INTRODUCTION

European guidelines for the diagnosis of celiac disease (CD) have been updated in 2020. The primary objective was to review the compliance with the diagnostic criteria for CD, according to ESPGHAN 2012. Secondarily, to describe the clinical characteristics of the patients and to assess the changes that would be implied by the application of the new 2020 criteria.

PATIENTS AND METHODS

Retrospective multicenter study in which 10 centers participated. Patients from 0 to 16 years old with a new diagnosis of CD in 2018-2019 were included. Clinical, serological variables and the performance of intestinal biopsy (IB) were collected.

RESULTS

163 patients were included (57% female) with a median age of 7.6 years (SD 4.4). The form of presentation was: 47.8% classical, 30.7% no classical and 21.5% asymptomatic, with differences depending on age. Total IgA and anti-transglutaminase IgA antibodies were performed in all centers as the first diagnostic step. IgA anti-endomysial antibodies (EMA) were performed in 80%, and HLA haplotype in 95%. Of the total, 78 cases (47.9%) met criteria for not performing intestinal biopsy (IB). IB was indicated in the remaining 85 patients, but was not performed in 29 cases (17.8%). The performance of IB was lower in the secondary hospitals than in the tertiary ones (p < 0.05). If we applied the ESPGHAN 2020 criteria, we would disregard the HLA study, and 21 more patients would not have required IB (going from 47.9% to 60.7% of the total).

CONCLUSIONS

Discrepancies are observed in the application of the ESPGHAN 2012 diagnostic criteria due to the different accessibility to EMA and endoscopic IB in secondary centers. With the ESPGHAN-2020 criteria, around 60% of patients will be able to be diagnosed without IB, provided that the determination of EMA is ensured.

Persistent Alterations in Plasma Lipid Profiles Before Introduction of Gluten in the Diet Associated With Progression to Celiac Disease

Celiac disease (CD) is a chronic enteropathy characterized by an autoimmune reaction in the small intestine of genetically susceptible individuals. The underlying causes of autoimmune reaction and its effect on host metabolism remain largely unknown. Herein, we apply lipidomics to elucidate the early events preceding clinical CD in a cohort of Finnish children, followed up in the Type 1 Diabetes Prediction and Prevention study.

President John F Kennedy’s medical history: coeliac disease and autoimmune polyglandular syndrome type 2

President John F. Kennedy (JFK) had a complex medical history that is now thought to be an autoimmune polyglandular syndrome type 2 with Addison’s disease and hypothyroidism. He also had gastrointestinal symptoms from adolescence, which now fit well with coeliac disease. In addition, he had a chronic back problem, which contributed to a chronic pain syndrome. This review looks at JFK’s various diseases and focusses on the history of coeliac disease, as well as its presentation. JFK’s Irish ancestry supports the hypothesis of a coeliac disease started early in his youth.

Anti-transglutaminase IgA antibody measurement in coeliac disease: Method comparison IDS-iSYS vs. Thermo Fisher Phadia

In coeliac disease, the diagnostic work-up is based on a combination of clinical, histopathological and serological evaluation. Among the serological tests, the presence of tissue transglutaminase (tTG) IgA antibodies is the cornerstone owed to a high sensitivity and specificity. Recently, Immunodiagnostic Systems Ltd (IDS) introduced the fully automated chemiluminescent autoimmune assays for use on the IDS-iSYS Multi-Discipline Automated System. In this study, we aimed to compare the performance of the IDS-iSYS assay to the Thermo Fisher Phadia assay and to establish the upper reference limit of tTG IgA in a healthy population from Denmark based on the IDS-iSYS assay. We discovered a total imprecision of CV = 12.2% (2.87 AU/mL) and CV = 10.6% (47.55 AU/mL). Moreover, we compared the performance of IDS-iSYS assay to Thermo Fisher Phadia assay in 236 samples from unselected patients submit for tTG IgA testing and found a concordance of 97% (p < .0001). Furthermore, in 150 healthy blood donors, we established the upper reference limit of 3.26 AU/mL (95% CI: 3.10 - 3.90) was identified. Our study validates the performance of the IDS-iSYS tTG IgA assay and demonstrates results in concordance with the established Thermo Fisher Phadia. Furthermore, it provides estimates for the upper reference interval limit of the tTG-IgA.

Dietary Patterns and Interventions to Alleviate Chronic Pain

Pain is one of the main problems for modern society and medicine, being the most common symptom described by almost all patients. When pain becomes chronic, the life of the patients is dramatically affected, being associated with significant emotional distress and/or functional disability. A complex biopsychosocial evaluation is necessary to better understand chronic pain, where good results can be obtained through interconnected biological, psychological, and social factors. The aim of this study was to find the most relevant articles existent in the PubMed database, one of the most comprehensive databases for medical literature, comprising dietary patterns to alleviate chronic pain. Through a combined search using the keywords "chronic pain" and "diet" limited to the last 10 years we obtained 272 results containing the types of diets used for chronic pain published in the PubMed database. Besides classical and alternative methods of treatment described in literature, it was observed that different diets are also a valid solution, due to many components with antioxidant and anti-inflammatory qualities capable to influence chronic pain and to improve the quality of life. Thirty-eight clinical studies and randomized controlled trials are analyzed, in an attempt to characterize present-day dietary patterns and interventions to alleviate chronic pain.

Influence of nutrition education in paediatric coeliac disease: impact of the role of the registered dietitian: a prospective, single-arm intervention study

BACKGROUND

The diagnosis of coeliac disease (CD) involves a change in the diet of the individual, which may influence their quality of life and nutritional status. The present study aimed to determine whether nutrition education by a registered dietitian is able to improve eating habits and body composition in children with CD.

METHODS

Dietary, physical activity and body composition changes were analysed, comparing baseline assessments with those 1 year after receiving education on healthy eating. At both time points, a 3-day dietary survey, a food frequency consumption questionnaire, an adherence to the Mediterranean diet test (Kidmed), duration of activity and an electrical bioimpedance study were conducted. Student's paired t-test and the McNemar test were also employed.

RESULTS

Seventy-two subjects (42 girls) with an mean (range) age of 10 (2-16) years were included. Before the intervention, an unbalanced diet was observed, rich in protein and fat, and deficient in complex carbohydrates. Only 14% consumed an adequate Mediterranean diet. After nutrition intervention, a significant increase in the consumption of plant-based foods and a concomitant decrease in meat, dairy and processed food intake (P < 0.001) were observed. Moreover, 92% of the patients (P < 0.001) managed to consume an adequate Mediterranean diet. Similarly, an increase was observed in the duration of physical activity undertaken [mean (SD) 1.02 (1.79) h, P < 0.001] and improvements in body composition were recorded, with a 17% decrease in fat mass percentage (P < 0.001).

CONCLUSIONS

Nutrition intervention focused on healthy eating is effective with respect to improving the nutritional status and diet quality in CD patients.

An updated overview of spectrum of gluten-related disorders: clinical and diagnostic aspects

The incidence of gluten-related disorders (GRDs) continues to increase and its global prevalence is estimated at approximately 5% of the population. Celiac disease (CD), dermatitis herpetiformis (DH), gluten ataxia (GA), wheat allergy (WA), and non-celiac gluten sensitivity (NCGS) are the five major GRDs that present with a wide range of clinical manifestations. The diagnosis of GRDs can be challenging because the typical and atypical clinical manifestations of the GRDs overlap. In this review, the current definitions of gluten-related disorders, focusing on their clinical features, diagnostic and therapeutic approaches are presented. We concluded that GRDs are usually diagnosed using a combination of clinical features, serological tests, and histopathological findings. Treatment usually involves dietary modification.

Gluten hypersensitivities and their impact on the production of gluten-free beer

This article consists of a study of the literature and an assessment of available data on the production of gluten-free beer and its constituents. The article shows how the FAO/WHO Codex Alimentarius Commission for Nutrition and Foods for Special Dietary Uses defines celiac disease, gluten-free products, and gluten-free beer. It describes diet-dependent diseases, which require a gluten-free diet, and groups of potential consumers of gluten-free beer. This article describes the use of oats as a raw material for the production of brewing malt and its usefulness in the production of beer. It specifies how the technological process of standard beer production needs to be modified so that the product meets the requirements of patients with celiac disease. The article also provides an overview of literature data on the production of gluten-free beer from pseudocereal malts, such as sorghum malt, buckwheat malt, amaranth malt, and quinoa malt.

Predictive Factors and Clinical Impact of Deep Remission in Celiac Disease

INTRODUCTION

The ultimate indicator of adherence to a gluten-free diet is the demonstration of mucosal healing. However, the need for histological reassessment is subject to controversy among "experts". The aim of this study was to evaluate celiac patients who underwent histological reevaluation after starting a gluten-free diet in order to identify those with histological remission and associated factors.

METHODS

This retrospective study included patients who agreed to a histological reassessment after apparent clinical and serological remission and reported at least 12 months of diet adherence. In all cases, informed consent was signed for upper endoscopy.

RESULTS

A total of 69 patients were included. In 67.9% of cases, the diagnosis was made in the context of "classic" symptomatology, 17% had "nonclassical" presentation, and 15.1% were in latent phase. 69.2% of the diagnoses were initially suspected by serology. Endoscopically, 11.8% of the patients did not present suggestive features macroscopically, and a histological grade of Marsh IIIa-c was observed in 75.5% of all cases. The histological findings were normalized in 37.7%, which was associated with the presence of lower Marsh score values at diagnosis (p = 0.014) and lower DEXA T-score values (p = 0.038). A histological improvement was observed in 55 patients (≥2 grades in 37 cases), which was related to the initial transferrin saturation (p = 0.027) and with higher Marsh scores at diagnosis (p = 0.007).

CONCLUSION

Even under a gluten-free diet, celiac histology normalization is difficult to obtain and appears to be independent of most clinical and serological findings at diagnosis. Patients with less severe histological levels at diagnosis reach remission more easily, but only represent the -minority of the population.

Effect of a Gluten-free Diet on Quality of Life in Patients With Nonclassical Versus Classical Presentations of Celiac Disease

BACKGROUND

Celiac disease (CD) often presents with symptoms of diarrhea and malabsorption, termed classical CD. However, it can also present as nonclassical CD, which is commonly associated with nongastrointestinal symptoms. Studies suggest that nonclassical CD tends to have less severe symptoms than classical CD, which may affect both adherence to a gluten-free diet (GFD) and psychological stress. Therefore, we compared adherence to a GFD and psychological measures, including quality of life (QOL) and somatization, between patients with nonclassical and classical presentations of CD.

METHODS

Patients at a tertiary care center with biopsy-proven CD, who completed a Talley Bowel Disease Questionnaire and the Short Form-36 at diagnosis and who had been on a GFD for at least 1 year, were included in this study. Patients were further surveyed to assess gastrointestinal symptoms, QOL, Somatization Symptom Checklist (SSC), and adherence to a GFD. Results were compared between patients with classical versus nonclassical CD presentation.

RESULTS

Among 122 patients included in this study, 62 had classical CD and 60 had nonclassical CD. At diagnosis, health-related QOL was lower in the classical CD group than in the nonclassical CD group. After following a GFD, both groups had improved QOL after following a GFD, and body mass index significantly increased in both groups. Most subscales of QOL, SSC scores, and adherence to the GFD were similar between the groups, except the Short Form-36 Mental Component summary scores that were still lower in the classical CD (48.4 vs. 52.6 nonclassical CD group; P=0.03).

CONCLUSIONS

Despite QOL at diagnosis being higher in those with nonclassical CD versus lower in those with classical CD, both groups had improved QOL and achieved a similar QOL after following a GFD.

Nutrition Assessment, Interventions, and Monitoring for Patients with Celiac Disease: An Evidence Analysis Center Scoping Review

The objectives of this scoping review were to identify and characterize studies examining nutrition assessment, interventions, and measures to monitor gluten-free diet (GFD) adherence/compliance in patients with celiac disease (CD). An electronic literature search of four databases (Cochrane Database for systematic reviews, CINAHL, Embase, and Ovid MEDLINE) was conducted to identify articles examining nutrition care in CD individuals. Except for narrative review, grey literature, and case study/report, all types of peer-reviewed articles published between January 2007 and August 2018 were eligible. There were a total of 10,823 records; 10,368 were excluded during the first round of screening due to irrelevancy and/or duplication. Of the 455 full-text articles that were assessed, 292 met the criteria and were included. Most of the studies were observational studies (n=212), followed by experimental trials (n=50), evidence-based practice guideline (EBPG)/report/statement (n=16), and systematic review (SR) (n=14). Nine original studies examined assessment, focusing mainly on different tools/ways to assess GFD adherence. The majority of the included original articles (n=235) were in the nutrition intervention category with GFD, oats, and prebiotics/probiotics as the top-three most studied interventions. There were eight SRs on GFD and five on oats. One SR and 21 original studies investigated the effectiveness of different measures to monitor GFD adherence/compliance. Although recent CD EBPGs were identified, different methods with varying levels of rigor, in terms of literature search and assessment of evidence strength, were used. Based on this scoping review, interventions focused on gluten-free diet and oats have been significantly covered by either SRs or EBPGs. Studies related to prebiotics/probiotics and education program/counseling focused interventions, as well as assessment, in CD patients have increased in recent years. Thus, it might be beneficial to conduct SRs/EBPGs focused on these topics to guide practitioners.

Improved HLA-based prediction of coeliac disease identifies two novel genetic interactions

Human Leucocyte Antigen (HLA) testing is useful in the clinical work-up of coeliac disease (CD) with high negative but low positive predictive value. We construct a genomic risk score (GRS) using HLA risk genotypes to improve CD prediction and guide exclusion criteria. Imputed HLA genotypes for five European CD case-control GWAS (n > 15,000) were used to construct and validate an interpretable HLA-based risk model (HDQ₁₅), which shows statistically significant improvements in predictive performance upon all previous HLA-based risk models. Conditioning on this model, we find two novel associations, HLA-DQ6.2 and HLA-DQ7.3, that interact significantly with HLA-DQ2.5 (p = 2.51 × 10^-9, 1.99 × 10^-7, respectively). Integrating these novel alleles into a new risk model (HDQ₁₇) leads to predictive performance equivalent or better than the strongest reported GRS (GRS₂₂₈) using 228 single nucleotide polymorphisms (SNPs). We also demonstrate that our proposed HLA-based models can be implemented using only six HLA tagging SNPs with statistically equivalent predictive performance. Using insights from our model to guide exclusionary criteria, we find the positive predictive value of CD testing in high-risk populations can be increased by 55%, from 17.5 to 27.1%, while maintaining a negative predictive value above 99%. Our results suggest that HLA typing is currently undervalued in CD assessment.

Efficacy of Gastrointestinal Endoscopy in 398 Patients With Iron Deficiency Anemia Who Lack Gastrointestinal Symptoms: Basrah Experience

Introduction

The diagnosis of iron deficiency anemia (IDA) relies heavily on symptom presentation, and patients lacking typical gastrointestinal (GI) symptoms represent a diagnostic challenge. IDA may be the initial manifestation of underlying pathology. This study sought to evaluate the effectiveness of different GI endoscopic studies in patients with IDA who lack GI symptoms.

Methods

We conducted an observational, multicenter retrospective analysis of 398 asymptomatic IDA patients admitted for GI endoscopic diagnosis from 2006 to 2016. Baseline measurements included hemoglobin, serum ferritin, mean corpuscular volume, serum iron, total iron-binding capacity, and transferrin saturation. We analyzed demographic characteristics, duration of hospital stay, the degree of severity of anemia, and endoscopic findings.

Results

The mean age of the study population was 52±9 years (range, 23 to 85 years), and 53% were men. Most patients were older than 45 years (n=353, 89%) with mild to moderate IDA. Patients underwent esophagogastroduodenoscopy (EGD, n=102), colonoscopy (n=271), or bidirectional endoscopy (n=25). The mean hospital stay was 2.72±1.66 days. The most common EGD results were atrophic gastritis (n=31), peptic ulcer (n=25), and negative findings (n=25). The most common colonoscopic results were negative findings (n=118), nonspecific colonic inflammatory changes (n=117), and non-bleeding hemorrhoids (n=29). We found no significant association between any endoscopic findings and age, gender, the severity of anemia, and length of hospitalization.

Conclusions

The presence of symptoms is of limited value in guiding diagnostic procedures concerning GI etiologies. Asymptomatic patients with IDA patients should receive an endoscopic examination irrespective of iron parameters, age, or gender for potentially treatable pathologies, especially for patients with suspected malignancies.

The Possible Role of Pathogenic and Non-Pathogenic Bacteria in Initiation and Exacerbation of Celiac Disease; A Comprehensive Review

Celiac Disease (CD) is an immune-mediated enteropathy, generally of the proximal intestine, that occurs in genetically susceptible individuals triggered by the ingestion of gluten. The incidence and frequency of CD are increasing, and it is predicted that CD affects approximately 1% of the people worldwide. The common clinical manifestations of CD are divided in two sections, including classic and non-classic symptoms that can be created in childhood and adulthood. The relationship between pathogenic and non-pathogenic bacteria with CD is complex and multidirectional. In previous published studies, results demonstrated the triggering impact of bacteria, viruses, and parasites on initiation and development of Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS). Different studies revealed the inducing effect of pathogenic and non-pathogenic bacteria on CD. However, increasing evidence proposes that some of these microorganisms can also play several positive roles in CD process. Although information of the pathogenesis of the CD is quickly expanding, the possible role of bacteria needs further examination. In conclusion, with respect to the possible correlation between different bacteria in CD, the current review-based study aims to discuss the possible relationship between CD and pathogenic and non-pathogenic bacteria and to show various and significant aspects of mechanisms involved in the CD process.

Coeliac Disease Pathogenesis: The Uncertainties of a Well-Known Immune Mediated Disorder

Coeliac disease is a common small bowel enteropathy arising in genetically predisposed individuals and caused by ingestion of gluten in the diet. Great advances have been made in understanding the role of the adaptive immune system in response to gluten peptides. Despite detailed knowledge of these adaptive immune mechanisms, the complete series of pathogenic events responsible for development of the tissue lesion remains less certain. This review contributes to the field by discussing additional mechanisms which may also contribute to pathogenesis. These include the production of cytokines such as interleukin-15 by intestinal epithelial cells and local antigen presenting cells as a pivotal event in the disease process. A subset of unconventional T cells called gamma/delta T cells are also persistently expanded in the coeliac disease (CD) small intestinal epithelium and recent analysis has shown that these cells contribute to pathogenic inflammation. Other unconventional T cell subsets may play a local immunoregulatory role and require further study. It has also been suggested that, in addition to activation of pathogenic T helper cells by gluten peptides, other peptides may directly interact with the intestinal mucosa, further contributing to the disease process. We also discuss how myofibroblasts, a major source of tissue transglutaminase and metalloproteases, may play a key role in intestinal tissue remodeling. Contribution of each of these factors to pathogenesis is discussed to enhance our view of this complex disorder and to contribute to a wider understanding of chronic immune-mediated disease.

Cognitive Impairment in Coeliac Disease with Respect to Disease Duration and Gluten-Free Diet Adherence: A Pilot Study

Cognitive deficit has been reported in coeliac disease (CD), but previous reports often study heterogenous samples of patients at multiple stages of the disease, or lack control data. Healthy controls (N = 21), newly diagnosed CD patients (NCD; N = 19) and established CD patients (ECD; N = 35) were recruited from a specialist UK centre. Participants underwent a cognitive test battery that established seven overall domain scores. The SF-36 was administered as a quality of life (QoL) measure. Controlling for age, data were compared in between-group ANCOVAs with Tukey’s post-hoc test. Any significant outcome was compared in the ECD group only, between patients who were gluten-free diet adherent vs. non-adherent (defined via Biagi score and serology results). NCD and ECD groups underperformed relative to controls, by comparable degrees, in visual (overall model: p < 0.001) and verbal (p = 0.046) memory. The ECD group only underperformed in visuoconstructive abilities (p = 0.050). Regarding QoL, the NCD group reported lower vitality (p = 0.030), while the ECD group reported more bodily pain (p = 0.009). Comparisons based on dietary adherence were non-significant. These findings confirm cognitive deficit in CD. Dysfunction appears established at the point of diagnosis, after which it (predominantly) stabilises. While a beneficial effect of dietary treatment is therefore implied, future research is needed to establish to what extent any further decline is due to gluten exposure.

Celiac Disease Diagnosed in an Older Adult Patient with a Complex Neuropsychiatric Involvement: A Case Report and Review of the Literature

We present a case of celiac disease (CD) diagnosis in a 75-year-old woman with a long-term history of chronic delusional jealousy and a complex neurological involvement. The case describes a very unusual clinical picture, provides some clinical clues, and highlights the importance of being aware of CD extraintestinal manifestations in order to get a timely diagnosis.

Persistent organic pollutant exposure and celiac disease: A pilot study

Celiac disease affects approximately 1% of the population worldwide. Little is known about environmental factors that may modulate risk in genetically susceptible populations. Persistent organic pollutants (POPs) are known endocrine disruptors and, given the interplay between the endocrine and immune systems, are plausible contributors to celiac disease. The current study aims to elucidate the association between POPs and celiac disease. We conducted a single-site pilot study of 88 patients recruited from NYU Langone's Hassenfeld Children's Hospital outpatient clinic, 30 of which were subsequently diagnosed with celiac disease using standard serology and duodenal biopsy examination. Polybrominated diphenyl ether (PBDEs), perfluoroalkyl substances (PFASs), and p,p'-dichlorodiphenyldichloroethylene (DDE) and HLA-DQ genotype category were measured in blood serum and whole blood, respectively. Multivariable logistic regressions were used to obtain odds ratios for celiac disease associated with serum POP concentrations. Controlling for sex, race, age, BMI, and genetic susceptibility score, patients with higher serum DDE concentrations had 2-fold higher odds of celiac disease (95% CI: 1.08, 3.84). After stratifying by sex, we found higher odds of celiac disease in females with serum concentrations of DDE (OR = 13.0, 95% CI = 1.54, 110), PFOS (OR = 12.8, 95% CI = 1.17, 141), perfluorooctanoic acid (OR = 20.6, 95% CI = 1.13, 375) and in males with serum BDE153, a PBDE congener (OR = 2.28, 95% CI = 1.01, 5.18). This is the first study to report on celiac disease with POP exposure in children. These findings raise further questions of how environmental chemicals may affect autoimmunity in genetically susceptible individuals.

Immunosuppression-induced clonal T-cell lymphoproliferative disease causing severe diarrhoea mimicking coeliac disease following renal transplantation: a case report

Background

Post-transplant lymphoproliferative disease is a recognized complication following solid organ transplantation. This is usually a B cell disease and frequently associated with Epstein Barr virus infection, although T cell PTLD can occur. T cell PTLD is usually a monomorphic, lymphomatous disease associated with an adverse prognosis.

Case report

We report a 52 year old male pre-emptive renal transplant recipient who developed severe diarrhea with weight loss following intensification of his immunosuppression due to antibody mediated rejection 3 years after transplantation. Duodenal biopsy demonstrated monoclonal CD8+ T cell duodenitis leading to increased intraepithlieal lymphocytes and sub-total villous atrophy mimicking coeliac disease. Coeliac disease was excluded by negative anti-tissue transglutaminase antibody, HLA-DQ2 and HLA-DQ8 testing. There was no evidence of lymphoma either on biopsy or CT enterography and no FDG avid disease on PET. Symptoms did not improve with reduction of immunosuppression, but resolved fully on complete withdrawal of treatment. The transplant failed and he was established on dialysis. The diagnosis was early PTLD.

Conclusions

Oesophagogastroduodenoscopy with small bowel biopsies is a useful investigation for determining the cause of diarrhoea in renal transplant patients when more common causes have been excluded. This is the first report that we are aware of clonal T cell PTLD mimicking coeliac disease which only resolved after complete withdrawal of immunosuppression. As treatments for lymphoma are aggressive they are only initiated in the malignant phase and management of early stage PTLD is to minimise risk of progression by reducing immunosuppression. Any plans to retransplant will have to take into consideration the possibility that PTLD will recur.

Pitfalls in the Diagnosis of Coeliac Disease and Gluten-Related Disorders

The spectrum of gluten-related disorders (GRD) has emerged as a relevant phenomenon possibly impacting on health care procedures and costs worldwide. Current classification of GRD is mainly based on their pathophysiology, and the following categories can be distinguished: immune-mediated disorders that include coeliac disease (CD), dermatitis herpetiformis (DH), and gluten ataxia (GA); allergic reactions such as wheat allergy (WA); and non-coeliac gluten sensitivity (NCGS), a condition characterized by both gastrointestinal and extra-intestinal symptoms subjectively believed to be induced by the ingestion of gluten/wheat that has recently gained popularity. Although CD, DH, and WA are well-defined clinical entities, whose diagnosis is based on specific diagnostic criteria, a diagnosis of NCGS may on the contrary be considered only after the exclusion of other organic disorders. Neither allergic nor autoimmune mechanisms have been found to be involved in NCGS. Mistakes in the diagnosis of GRD are still a relevant clinical problem that may result in overtreatment of patients being unnecessary started on a gluten-free diet and waste of health-care resources. On the basis of our clinical experience and literature, we aim to identify the main pitfalls in the diagnosis of CD and its complications, DH, and WA. We provide a practical methodological approach to guide clinicians on how to recognize and avoid them.

The Epidemiology of Celiac Disease in the General Population and High-Risk Groups in Arab Countries: A Systematic Review

Background and Aims

Celiac disease (CD) is possibly the most common autoimmune disorder, which may lead to dietary problems in the Arab region. This paper is aimed at exploring the epidemiology of the celiac disease in Arab countries, including its prevalence, associated risk factors, and clinical patterns.

Methods

An extensive search of the literature was conducted from electronic databases such as PubMed, Embase, and Google Scholar. In total, 134 research papers were retrieved. We extracted studies published from January 1996 to December 2019. Our search was limited to studies published in English. Findings. The review included 35 studies with 22,340 participants from 12 countries and demonstrated a wide variation in the prevalence of CD. The highest prevalence among the general population (3.2%) was reported in Saudi Arabia, and the lowest (0.1%) was reported in Tunisia. Women demonstrated a higher prevalence of celiac disease relative to men. The peak age at diagnosis fell between 1 and 3 years and 9-10 years. Most studies focused on type 1 diabetes. Children with type 1 diabetes have a higher prevalence of CD (range from 5.5% to 20%), while the prevalence of CD in Down's syndrome patients was 1.1% and 10.7% in UAE and Saudi Arabia, respectively. Other autoimmune diseases associated with CD are thyroid disease and irritable bowel disease. The most widely recognized clinical presentation was an inability to flourish and poor weight gain, followed by short stature, abdominal pain, abdominal distension, bloating, and chronic diarrhea.

Conclusion

The prevalence of the celiac disease in Arab countries varies with sex and age. However, we found that celiac disease presented similar clinical characteristics independent of the geographic region. Longitudinal population-based studies are needed to better identify the true burden and determinants of celiac disease.