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Shiha MG, Sanders DS. What is new in the management of coeliac disease? Eur J Intern Med 2025; 134:1-8. [PMID: 39894725 DOI: 10.1016/j.ejim.2025.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Revised: 01/25/2025] [Accepted: 01/29/2025] [Indexed: 02/04/2025]
Abstract
Coeliac disease is the most common immune-mediated enteropathy, affecting approximately 1 % of the population worldwide. Currently, the vast majority of individuals remain undiagnosed. Coeliac disease is triggered by gluten ingestion in genetically predisposed individuals carrying the human leukocyte antigen (HLA) genes; HLA-DQ2 and HLA-DQ8. Patients with coeliac disease present with a wide spectrum of gastrointestinal and extraintestinal manifestations and, in some cases, without any symptoms. The diagnosis of coeliac disease in adults is based on a combination of clinical suspicion, positive serological markers and histological evidence of small intestinal atrophy on duodenal biopsies. The only effective treatment is a strict, lifelong gluten-free diet. However, up to 20 % of patients report persistent or recurrent symptoms. In this review, we provide a comprehensive update on coeliac disease, focusing on its relevance to the different medical specialities and highlighting the need for a multidisciplinary approach to its diagnosis and management. Clinicians practicing internal medicine have a unique opportunity to diagnose this multisystem autoimmune disease. By doing so, they would avoid delays in diagnosis for these patients. A low threshold for serological testing is recommended.
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Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK.
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
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Husby S, Choung RS, Crawley C, Lillevang ST, Murray JA. Laboratory Testing for Celiac Disease: Clinical and Methodological Considerations. Clin Chem 2024; 70:1208-1219. [PMID: 39099386 DOI: 10.1093/clinchem/hvae098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 05/30/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Celiac disease (CeD) has an estimated prevalence of 1%-3%. The classical clinical presentation is malabsorption, but now patients may present with more subtle symptoms such as constipation, osteoporosis, or iron deficiency anemia. Children may also present with poor growth.CeD has a strong genetic component, and high-risk groups include first-degree relatives with CeD, patients with co-existing autoimmune diseases, and patients with chromosomal aberrations. CONTENT Diagnostic tests for CeD include duodenal histology, serology, and genetic testing. Duodenal histology has traditionally been the gold standard of diagnosis. However, serological tests, especially IgA tissue transglutaminase antibodies (TTG-IgA), are widely used and diagnostic algorithms are based primarily on TTG-IgA as a starting point. Human leukocyte antigen typing may also be incorporated to determine genetic risk for CeD. Guidelines for children endorse biopsy avoidance provided high levels of TTG-IgA, with diagnostic accuracy being comparable to duodenal biopsy. Confirmation may be achieved by identifying IgA endomysial antibodies in a separate blood sample. Subjects with low positive TTG-IgA levels and subjects with IgA deficiency need a biopsy to establish a diagnosis of CeD. The clinical follow-up of CeD usually includes a repeat TTG-IgA examination. In adults, healing may be delayed or incomplete, and a rare consequence of refractory celiac disease is transformation to enteric T-cell lymphoma. SUMMARY Laboratory testing, in particular TTG-IgA, plays a central role in the diagnosis and has an accuracy comparable to histology. Diagnostic algorithms utilizing laboratory testing are critical for the development of novel strategies to improve diagnosis.
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Affiliation(s)
- Steffen Husby
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Cæcilie Crawley
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Søren T Lillevang
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
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3
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Shiha MG, Hadjisavvas N, Sanders DS, Penny HA. Optimising the Diagnosis of Adult Coeliac Disease: Current Evidence and Future Directions. Br J Hosp Med (Lond) 2024; 85:1-21. [PMID: 39347683 DOI: 10.12968/hmed.2024.0362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2024]
Abstract
Coeliac disease is a common autoimmune disorder that affects nearly 1% of the general population. Current diagnostic strategies involve active case finding, serological tests, and endoscopy with biopsies. However, many patients with coeliac disease remain undiagnosed due to a wide gap between clinical guidelines and real-world practice in the diagnosis of adult coeliac disease. This highlights the need for increased education, training, and targeted quality-improvement interventions to optimise the diagnosis of coeliac disease.
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Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | | | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
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Durán-Rosas C, Lara-Carmona J, Hernández-Flores K, Cabrera-Jorge FJ, Roesch-Dietlen F, Amieva-Balmori M, Vivanco-Cid H, Santiesteban-González S, Thomas-Dupont P, Remes-Troche JM. Celiac disease seroprevalence in subjects with dyspeptic symptoms. A study on a Mexican population. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:243-248. [PMID: 37833136 DOI: 10.1016/j.rgmxen.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/22/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION AND AIMS Celiac disease (CD) is an autoimmune enteropathy that develops in genetically susceptible individuals. The typical gastrointestinal manifestation is diarrhea but symptoms of dyspepsia, such as epigastric pain, nausea, or satiety, can sometimes appear. Previous studies have reported that the prevalence of CD in patients with dyspepsia can be as high as 7%. The aim of the present study was to evaluate CD seroprevalence in subjects with dyspeptic symptoms and a control group in a Mexican population. MATERIAL AND METHODS A case-control study was conducted on blood donors that answered the PAGI-SYM questionnaire for dyspepsia and in whom IgA antibodies to tissue transglutaminase 2 (IgA anti-tTG2) and IgG antibodies to deamidated gliadin peptide (IgG anti-DGP) were determined. CD seroprevalence in subjects with dyspeptic symptoms and in asymptomatic subjects was compared. RESULTS A total of 427 subjects (76.3% men), with a mean patient age of 34 years (range of 18-65 years) were included. Of those participants, 87 (20.3%) had symptoms of dyspepsia (group A) and 340 (79.6%) were asymptomatic (group B). Antibodies were positive in one (1.15%) of the group A subjects (1/87, 95% CI 0.2-6 %), whereas they were positive in 4 (1.18%) of the group B subjects (4/340, 95% CI 0.4-2.9%, p = 0.59). CONCLUSIONS CD seroprevalence in the study population with dyspeptic symptoms (1%) was not different from that of the control population. Thus, CD screening in Mexican patients with dyspepsia is not justified.
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Affiliation(s)
- C Durán-Rosas
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - J Lara-Carmona
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico.
| | - K Hernández-Flores
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - F J Cabrera-Jorge
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - F Roesch-Dietlen
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - H Vivanco-Cid
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | | | - P Thomas-Dupont
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
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Keeney E, Elwenspoek MMC, Jackson J, Roadevin C, Jones HE, O'Donnell R, Sheppard AL, Dawson S, Lane D, Stubbs J, Everitt H, Watson JC, Hay AD, Gillett P, Robins G, Mallett S, Whiting PF, Thom H. Identifying the Optimum Strategy for Identifying Adults and Children With Celiac Disease: A Cost-Effectiveness and Value of Information Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:301-312. [PMID: 38154593 DOI: 10.1016/j.jval.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 11/08/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVES Celiac disease (CD) is thought to affect around 1% of people in the United Kingdom, but only approximately 30% are diagnosed. The aim of this work was to assess the cost-effectiveness of strategies for identifying adults and children with CD in terms of who to test and which tests to use. METHODS A decision tree and Markov model were used to describe testing strategies and model long-term consequences of CD. The analysis compared a selection of pre-test probabilities of CD above which patients should be screened, as well as the use of different serological tests, with or without genetic testing. Value of information analysis was used to prioritize parameters for future research. RESULTS Using serological testing alone in adults, immunoglobulin A (IgA) tissue transglutaminase (tTG) at a 1% pre-test probability (equivalent to population screening) was most cost-effective. If combining serological testing with genetic testing, human leukocyte antigen combined with IgA tTG at a 5% pre-test probability was most cost-effective. In children, the most cost-effective strategy was a 10% pre-test probability with human leukocyte antigen plus IgA tTG. Value of information analysis highlighted the probability of late diagnosis of CD and the accuracy of serological tests as important parameters. The analysis also suggested prioritizing research in adult women over adult men or children. CONCLUSIONS For adults, these cost-effectiveness results suggest UK National Screening Committee Criteria for population-based screening for CD should be explored. Substantial uncertainty in the results indicate a high value in conducting further research.
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Affiliation(s)
- Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK.
| | - Martha M C Elwenspoek
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK
| | - Joni Jackson
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK
| | - Cristina Roadevin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Rachel O'Donnell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK
| | - Athena L Sheppard
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol, England, UK; Swansea University Medical School, Swansea University, Swansea, England, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | | | | | - Hazel Everitt
- Primary Care Research Centre, Population Sciences and Medical Education, University of Southampton, Southampton, England, UK
| | - Jessica C Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Alastair D Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh EH9 1LF Scotland, England, UK
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, England, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London, London, England, UK
| | - Penny F Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
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Al-Hussaini A, Troncone R, Alobaid S, Bashir MS. Status of vitamins and minerals in children with screening-identified celiac disease: A case-control study. J Pediatr Gastroenterol Nutr 2024; 78:677-684. [PMID: 38504391 DOI: 10.1002/jpn3.12126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 12/06/2023] [Accepted: 12/10/2023] [Indexed: 03/21/2024]
Abstract
OBJECTIVES Micronutrient deficiencies characterize classical "late-diagnosed" celiac disease (CeD). This study aimed to identify the prevalence of micronutrient deficiencies among children with "early-diagnosed" screening-identified CeD to determine the clinical value of routine testing for deficiencies in those patients. METHODS A case-control study was conducted on screening-identified CeD patients diagnosed during a mass screening study (84 patients, mean age 11.3 ± 2.6 years). The controls (443 children, mean age 10.8 ± 2.5 years) were negative for celiac disease serological screening. Hemoglobin, serum levels of iron, ferritin, folate, vitamin B12, vitamin A, vitamin E, 25-OH vitamin D, zinc, and selenium were measured. RESULTS The mean serum levels of hemoglobin, iron, ferritin, vitamin D, zinc, copper, and selenium were significantly lower in CeD patients than in healthy controls (hemoglobin 12.56 vs. 13.02 g/dL [p = 0.04]; iron 10.61 vs. 17.6 µmol/L [p < 0.001], ferritin 25.7 vs. 48.3 µg/L [p < 0.001], vitamin D 29.1 vs. 37.5 nmol/L, zinc 11.9 vs. 21.7 µmol/L, copper 18.9 vs. 32.5 µmol/L, selenium 1.04 vs. 1.36 µmol/L; p < 0.001). Patients with celiac and severe intestinal damage (Marsh IIIb and IIIc) had significantly lower serum ferritin and vitamin A levels than patients with mild intestinal damage (Marsh II and IIIa) (ferritin 15 vs. 22 µg/L, p < 0.025; vitamin A 0.85 vs. 1.35 µmol/L, p = 0.007). CONCLUSION Micronutrient deficiencies are still detectable in "early-diagnosed" screening-identified CeD cases, a clinically relevant result that strongly supports efforts for screening and early diagnosis of CeD.
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Affiliation(s)
- Abdulrahman Al-Hussaini
- Division of Pediatric Gastroenterology, Children's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University
- Department of Pediatrics, Faculty of Medicine, Prince Abdullah bin Khalid Celiac Disease Research Chair, King Saud University
| | - Riccardo Troncone
- Department of Medical Translational Sciences & European Laboratory for the Investigation of Food-Induced Diseases, University Federico II, Naples, Italy
| | - Suzan Alobaid
- Department of Nutrition, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Muhammed Salman Bashir
- Department of Biostatistics, Research Services Adminsitration, Research Center, King Fahad Medical City, Riyadh, Riyadh, Saudi Arabia
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7
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Lebwohl B, Ma C, Lagana SM, Pai RK, Baker KA, Zayadi A, Hogan M, Bouma G, Cellier C, Goldsmith JD, Lundin KEA, Pinto-Sanchez MI, Robert ME, Rubio-Tapia A, Sanders DS, Schaeffer DF, Semrad CE, Silvester JA, Verdú EF, Verma R, Wu TT, Feagan BG, Crowley E, Jairath V, Murray JA. Standardizing Randomized Controlled Trials in Celiac Disease: An International Multidisciplinary Appropriateness Study. Gastroenterology 2024; 166:88-102. [PMID: 37704112 PMCID: PMC12055257 DOI: 10.1053/j.gastro.2023.08.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/22/2023] [Accepted: 08/30/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND & AIMS There is a need to develop safe and effective pharmacologic options for the treatment of celiac disease (CeD); however, consensus on the appropriate design and configuration of randomized controlled trials (RCTs) in this population is lacking. METHODS A 2-round modified Research and Development/University of California Los Angeles Appropriateness Method study was conducted. Eighteen gastroenterologists (adult and pediatric) and gastrointestinal pathologists voted on statements pertaining to the configuration of CeD RCTs, inclusion and exclusion criteria, gluten challenge, and trial outcomes. Two RCT designs were considered, representing the following distinct clinical scenarios for which pharmacotherapy may be used: trials incorporating a gluten challenge to simulate exposure; and trials evaluating reversal of histologic changes, despite attempted adherence to a gluten-free diet. Each statement was rated as appropriate, uncertain, or inappropriate, using a 9-point Likert scale. RESULTS For trials evaluating prevention of relapse after gluten challenge, participants adherent to a gluten-free diet for 12 months or more with normal or near-normal-sized villi should be enrolled. Gluten challenge should be FODMAPS (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) free, and efficacy evaluated using histology with a secondary patient-reported outcome measure. For trials evaluating reversal of villus atrophy, the panel voted it appropriate to enroll participants with a baseline villus height to crypt depth ratio ≤2 and measure efficacy using a primary histologic end point. Guidance for measuring histologic, endoscopic, and patient-reported outcomes in adult and pediatric patients with CeD are provided, along with recommendations regarding the merits and limitations of different end points. CONCLUSIONS We developed standardized recommendations for clinical trial design, eligibility criteria, outcome measures, gluten challenge, and disease evaluations for RCTs in patients with CeD.
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Affiliation(s)
- Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Alimentiv Inc, London, Ontario, Canada.
| | - Stephen M Lagana
- Department of Pathology and Cell Biology, Columbia University, New York, New York
| | - Rish K Pai
- Department of Pathology and Laboratory Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | | | | | | | - Gerd Bouma
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, The Netherlands
| | - Christophe Cellier
- Department of Gastroenterology, University of Paris-Cité, Georges-Pompidou European Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | | | - Knut E A Lundin
- Norwegian Coeliac Disease Research Centre, University of Oslo Faculty of Medicine, Oslo, Norway; Department of Gastroenterology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Maria I Pinto-Sanchez
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Marie E Robert
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Alberto Rubio-Tapia
- Celiac Disease Program, Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - David F Schaeffer
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Carol E Semrad
- Department of Gastroenterology, University of Chicago, Chicago, Illinois
| | - Jocelyn A Silvester
- Harvard Celiac Research Program, Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Celiac Disease Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Elena F Verdú
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Ritu Verma
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago, Chicago, Illinois
| | - Tsung-Teh Wu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Brian G Feagan
- Alimentiv Inc, London, Ontario, Canada; Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Eileen Crowley
- Alimentiv Inc, London, Ontario, Canada; Division of Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital Western Ontario, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Vipul Jairath
- Alimentiv Inc, London, Ontario, Canada; Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Is There a Need to Undertake Conventional Gastroscopy and Biopsy When Making the Diagnosis of Coeliac Disease in Adults? J Clin Gastroenterol 2023; 57:139-142. [PMID: 36598805 DOI: 10.1097/mcg.0000000000001806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Celiac disease is a common autoimmune condition characterized by small intestinal inflammation and mucosal damage triggered by an inappropriate immune response to ingested gluten. Gastroscopy and duodenal biopsy are currently the gold standard approach to diagnosing celiac disease in adults. However, the emergence of highly accurate serological tests for celiac disease in the last 2 decades led to a change in the pediatric guidelines to diagnose celiac disease without biopsy in selected patients. Adopting this no-biopsy approach to diagnose celiac disease in adults remains controversial, but the evidence supporting it is growing.
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Denholm J, Schreiber B, Evans S, Crook O, Sharma A, Watson J, Bancroft H, Langman G, Gilbey J, Schönlieb CB, Arends M, Soilleux E. Multiple-instance-learning-based detection of coeliac disease in histological whole-slide images. J Pathol Inform 2022; 13:100151. [PMID: 36605111 PMCID: PMC9808019 DOI: 10.1016/j.jpi.2022.100151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/21/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
We present a multiple-instance-learning-based scheme for detecting coeliac disease, an autoimmune disorder affecting the intestine, in histological whole-slide images (WSIs) of duodenal biopsies. We train our model to detect 2 distinct classes, normal tissue and coeliac disease, on the patch-level, and in turn leverage slide-level classifications. Using 5-fold cross-validation in a training set of 1841 (1163 normal; 680 coeliac disease) WSIs, our model classifies slides as normal with accuracy (96.7±0.6)%, precision (98.0±1.7)%, and recall (96.8±2.5)%, and as coeliac disease with accuracy (96.7±0.5)%, precision (94.9±3.7)%, and recall (96.5±2.9)% where the error bars are the cross-validation standard deviation. We apply our model to 2 test sets: one containing 191 WSIs (126 normal; 65 coeliac) from the same sources as the training data, and another from a completely independent source, containing 34 WSIs (17 normal; 17 coeliac), obtained with a scanner model not represented in the training data. Using the same-source test data, our model classifies slides as normal with accuracy 96.5%, precision 98.4% and recall 96.1%, and positive for coeliac disease with accuracy 96.5%, precision 93.5%, and recall 97.3%. Using the different-source test data the model classifies slides as normal with accuracy 94.1% (32/34), precision 89.5%, and recall 100%, and as positive for coeliac disease with accuracy 94.1%, precision 100%, and recall 88.2%. We discuss generalising our approach to screen for a range of pathologies.
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Affiliation(s)
- J. Denholm
- Lyzeum Ltd, Salisbury House, Station Road, Cambridge CB1 2LA, Cambridgeshire, UK
- Department of Applied Maths and Theoretical Physics, University of Cambridge, Centre for Mathematical Sciences, Wilberforce Road, Cambridge CB3 0WA, Cambridgeshire, UK
- Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, Cambridgeshire, UK
| | - B.A. Schreiber
- Department of Applied Maths and Theoretical Physics, University of Cambridge, Centre for Mathematical Sciences, Wilberforce Road, Cambridge CB3 0WA, Cambridgeshire, UK
- Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, Cambridgeshire, UK
| | - S.C. Evans
- Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, Cambridgeshire, UK
| | - O.M. Crook
- The Alan Turing Institute, 96 Euston Rd, London NW1 2DB, UK
| | - A. Sharma
- Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, Cambridgeshire, UK
| | - J.L. Watson
- Oxford Medical School, University of Oxford, S Parks Road, Oxford OX1 3PL, Oxfordshire, UK
| | - H. Bancroft
- Department of Cellular Pathology, Birmingham Heartlands Hospital, University Hospitals Birmingham, 45 Bordesley Green East, Birmingham B9 5SS, West Midlands, UK
| | - G. Langman
- Department of Cellular Pathology, Birmingham Heartlands Hospital, University Hospitals Birmingham, 45 Bordesley Green East, Birmingham B9 5SS, West Midlands, UK
| | - J.D. Gilbey
- Department of Applied Maths and Theoretical Physics, University of Cambridge, Centre for Mathematical Sciences, Wilberforce Road, Cambridge CB3 0WA, Cambridgeshire, UK
| | - C.-B. Schönlieb
- Department of Applied Maths and Theoretical Physics, University of Cambridge, Centre for Mathematical Sciences, Wilberforce Road, Cambridge CB3 0WA, Cambridgeshire, UK
| | - M.J. Arends
- Division of Pathology, University of Edinburgh, Cancer Research UK Edinburgh Centre, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XR, Lothian, Scotland
| | - E.J. Soilleux
- Lyzeum Ltd, Salisbury House, Station Road, Cambridge CB1 2LA, Cambridgeshire, UK
- Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, Cambridgeshire, UK
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Elwenspoek MM, Thom H, Sheppard AL, Keeney E, O'Donnell R, Jackson J, Roadevin C, Dawson S, Lane D, Stubbs J, Everitt H, Watson JC, Hay AD, Gillett P, Robins G, Jones HE, Mallett S, Whiting PF. Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling. Health Technol Assess 2022; 26:1-310. [PMID: 36321689 PMCID: PMC9638887 DOI: 10.3310/zuce8371] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Coeliac disease is an autoimmune disorder triggered by ingesting gluten. It affects approximately 1% of the UK population, but only one in three people is thought to have a diagnosis. Untreated coeliac disease may lead to malnutrition, anaemia, osteoporosis and lymphoma. OBJECTIVES The objectives were to define at-risk groups and determine the cost-effectiveness of active case-finding strategies in primary care. DESIGN (1) Systematic review of the accuracy of potential diagnostic indicators for coeliac disease. (2) Routine data analysis to develop prediction models for identification of people who may benefit from testing for coeliac disease. (3) Systematic review of the accuracy of diagnostic tests for coeliac disease. (4) Systematic review of the accuracy of genetic tests for coeliac disease (literature search conducted in April 2021). (5) Online survey to identify diagnostic thresholds for testing, starting treatment and referral for biopsy. (6) Economic modelling to identify the cost-effectiveness of different active case-finding strategies, informed by the findings from previous objectives. DATA SOURCES For the first systematic review, the following databases were searched from 1997 to April 2021: MEDLINE® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), Cochrane Library, Web of Science™ (Clarivate™, Philadelphia, PA, USA), the World Health Organization International Clinical Trials Registry Platform ( WHO ICTRP ) and the National Institutes of Health Clinical Trials database. For the second systematic review, the following databases were searched from January 1990 to August 2020: MEDLINE, Embase, Cochrane Library, Web of Science, Kleijnen Systematic Reviews ( KSR ) Evidence, WHO ICTRP and the National Institutes of Health Clinical Trials database. For prediction model development, Clinical Practice Research Datalink GOLD, Clinical Practice Research Datalink Aurum and a subcohort of the Avon Longitudinal Study of Parents and Children were used; for estimates for the economic models, Clinical Practice Research Datalink Aurum was used. REVIEW METHODS For review 1, cohort and case-control studies reporting on a diagnostic indicator in a population with and a population without coeliac disease were eligible. For review 2, diagnostic cohort studies including patients presenting with coeliac disease symptoms who were tested with serological tests for coeliac disease and underwent a duodenal biopsy as reference standard were eligible. In both reviews, risk of bias was assessed using the quality assessment of diagnostic accuracy studies 2 tool. Bivariate random-effects meta-analyses were fitted, in which binomial likelihoods for the numbers of true positives and true negatives were assumed. RESULTS People with dermatitis herpetiformis, a family history of coeliac disease, migraine, anaemia, type 1 diabetes, osteoporosis or chronic liver disease are 1.5-2 times more likely than the general population to have coeliac disease; individual gastrointestinal symptoms were not useful for identifying coeliac disease. For children, women and men, prediction models included 24, 24 and 21 indicators of coeliac disease, respectively. The models showed good discrimination between patients with and patients without coeliac disease, but performed less well when externally validated. Serological tests were found to have good diagnostic accuracy for coeliac disease. Immunoglobulin A tissue transglutaminase had the highest sensitivity and endomysial antibody the highest specificity. There was little improvement when tests were used in combination. Survey respondents (n = 472) wanted to be 66% certain of the diagnosis from a blood test before starting a gluten-free diet if symptomatic, and 90% certain if asymptomatic. Cost-effectiveness analyses found that, among adults, and using serological testing alone, immunoglobulin A tissue transglutaminase was most cost-effective at a 1% pre-test probability (equivalent to population screening). Strategies using immunoglobulin A endomysial antibody plus human leucocyte antigen or human leucocyte antigen plus immunoglobulin A tissue transglutaminase with any pre-test probability had similar cost-effectiveness results, which were also similar to the cost-effectiveness results of immunoglobulin A tissue transglutaminase at a 1% pre-test probability. The most practical alternative for implementation within the NHS is likely to be a combination of human leucocyte antigen and immunoglobulin A tissue transglutaminase testing among those with a pre-test probability above 1.5%. Among children, the most cost-effective strategy was a 10% pre-test probability with human leucocyte antigen plus immunoglobulin A tissue transglutaminase, but there was uncertainty around the most cost-effective pre-test probability. There was substantial uncertainty in economic model results, which means that there would be great value in conducting further research. LIMITATIONS The interpretation of meta-analyses was limited by the substantial heterogeneity between the included studies, and most included studies were judged to be at high risk of bias. The main limitations of the prediction models were that we were restricted to diagnostic indicators that were recorded by general practitioners and that, because coeliac disease is underdiagnosed, it is also under-reported in health-care data. The cost-effectiveness model is a simplification of coeliac disease and modelled an average cohort rather than individuals. Evidence was weak on the probability of routine coeliac disease diagnosis, the accuracy of serological and genetic tests and the utility of a gluten-free diet. CONCLUSIONS Population screening with immunoglobulin A tissue transglutaminase (1% pre-test probability) and of immunoglobulin A endomysial antibody followed by human leucocyte antigen testing or human leucocyte antigen testing followed by immunoglobulin A tissue transglutaminase with any pre-test probability appear to have similar cost-effectiveness results. As decisions to implement population screening cannot be made based on our economic analysis alone, and given the practical challenges of identifying patients with higher pre-test probabilities, we recommend that human leucocyte antigen combined with immunoglobulin A tissue transglutaminase testing should be considered for adults with at least a 1.5% pre-test probability of coeliac disease, equivalent to having at least one predictor. A more targeted strategy of 10% pre-test probability is recommended for children (e.g. children with anaemia). FUTURE WORK Future work should consider whether or not population-based screening for coeliac disease could meet the UK National Screening Committee criteria and whether or not it necessitates a long-term randomised controlled trial of screening strategies. Large prospective cohort studies in which all participants receive accurate tests for coeliac disease are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42019115506 and CRD42020170766. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 44. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martha Mc Elwenspoek
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Howard Thom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athena L Sheppard
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachel O'Donnell
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joni Jackson
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cristina Roadevin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Hazel Everitt
- Primary Care Research Centre, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Jessica C Watson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Gillett
- Paediatric Gastroenterology, Hepatology and Nutrition Department, Royal Hospital for Sick Children, Edinburgh, UK
| | - Gerry Robins
- Department of Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London, London, UK
| | - Penny F Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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11
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Aon M, Taha S, Mahfouz K, Ibrahim MM, Aoun AH. Vitamin B12 (Cobalamin) Deficiency in Overt and Subclinical Primary Hypothyroidism. Clin Med Insights Endocrinol Diabetes 2022; 15:11795514221086634. [PMID: 35340751 PMCID: PMC8943463 DOI: 10.1177/11795514221086634] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background: B12 (cobalamin) deficiency has been reported in hypothyroid patients with
variable prevalence rates thus routine screening of hypothyroid patients was
recommended by some and discouraged by others. We aimed to assess the
prevalence of B12 deficiency among hypothyroid patients and to evaluate for
pernicious anemia and celiac disease as etiologies. Methods: A total 133 patients were included. Thyroid hormones and thyroid peroxidase
(TPO) autoantibodies were measured. Serum B12 was measured and if deficient,
intrinsic factor antibodies (IFAB) and tissue transglutaminase (tTG)
antibodies were evaluated. Results: Our study included 45 patients with overt hypothyroidism (OH), 48 patients
with subclinical hypothyroidism (SCH), and 40 patients as controls. Mean age
was 34.3 years and 82% were females. TPO antibodies were positive in 73.5%
of OH and 51.1% of SCH patients. B12 deficiency was detected in 33.3%,
47.9%, and 37.5% of OH, SCH, and controls, respectively with no significant
difference (P = .334). Borderline-to-low B12 level was more
prevalent in the OH and the SCH groups compared to controls (68.9%, 85.4%,
and 57.5%, respectively; P = .014). Among B12-deficient
hypothyroid patients, 7.5% had positive IFAB and 13.3% had positive tTG
antibodies. We did not find a significant association of TPO positivity and
B12 deficiency (OR, 0.69; 95% CI 0.3-1.57; P = .147). Conclusion: We did not find a higher prevalence of B12 deficiency among hypothyroid
patients nor an association with TPO positivity. Borderline B12 levels were
more prevalent among hypothyroid patients.
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Affiliation(s)
- Mohamed Aon
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Sherif Taha
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Giza, Egypt.,Department of Internal Medicine, Jahra Hospital, Jahra, Kuwait
| | - Khaled Mahfouz
- Department of Internal Medicine, Jahra Hospital, Jahra, Kuwait
| | - Mohamed M Ibrahim
- Department of Clinical Pharmacology, Jahra Hospital, Jahra, Kuwait.,Department of Clinical Pharmacology, 6th October University, 6th October city, Egypt
| | - Ahmed H Aoun
- Department of Pediatrics, Faculty of Medicine, Cairo University, Giza, Egypt
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12
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McFarlane M, Arasaradnam RP, Reed B, Daulton E, Wicaksono A, Tyagi H, Covington JA, Nwokolo C. Minimal Gluten Exposure Alters Urinary Volatile Organic Compounds in Stable Coeliac Disease. SENSORS (BASEL, SWITZERLAND) 2022; 22:s22031290. [PMID: 35162037 PMCID: PMC8839331 DOI: 10.3390/s22031290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 05/04/2023]
Abstract
Coeliac disease (CD) patients are distinguishable from healthy individuals via urinary volatile organic compounds (VOCs) analysis. We exposed 20 stable CD patients on gluten-free diet (GFDs) to a 14-day, 3 g/day gluten challenge (GCh), and assessed urinary VOC changes. A control cohort of 20 patients continued on GFD. Urine samples from Days 0, 7, 14, 28 and 56 were analysed using Lonestar FAIMS and Markes Gas Chromatography-Time of Flight-Mass Spectrometer (GC-TOF-MS). VOC signatures on D (day) 7-56 were compared with D0. Statistical analysis was performed using R. In GCh patients, FAIMS revealed significant VOC differences for all time points compared to D0. GC-TOF-MS revealed significant changes at D7 and D14 only. In control samples, FAIMS revealed significant differences at D7 only. GC-TOF-MS detected no significant differences. Chemical analysis via GC-MS-TOF revealed 12 chemicals with significantly altered intensities at D7 vs. D0 for GCh patients. The alterations persisted for six chemicals at D14 and one (N-methyltaurine) remained altered after D14. This low-dose, short-duration challenge was well tolerated. FAIMS and GC-TOF-MS detected VOC signature changes in CD patients when undergoing a minimal GCh. These findings suggest urinary VOCs could have a role in monitoring dietary compliance in CD patients.
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Affiliation(s)
- Michael McFarlane
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK; (R.P.A.); (C.N.)
- Correspondence:
| | - Ramesh P. Arasaradnam
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK; (R.P.A.); (C.N.)
- Faculty of Health Science, University of Coventry, Coventry CV2 2DX, UK
| | - Beryl Reed
- Department of Dietetics, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK;
| | - Emma Daulton
- School of Engineering, University of Warwick, Coventry CV4 7AL, UK; (E.D.); (A.W.); (H.T.); (J.A.C.)
| | - Alfian Wicaksono
- School of Engineering, University of Warwick, Coventry CV4 7AL, UK; (E.D.); (A.W.); (H.T.); (J.A.C.)
| | - Heena Tyagi
- School of Engineering, University of Warwick, Coventry CV4 7AL, UK; (E.D.); (A.W.); (H.T.); (J.A.C.)
| | - James A. Covington
- School of Engineering, University of Warwick, Coventry CV4 7AL, UK; (E.D.); (A.W.); (H.T.); (J.A.C.)
| | - Chuka Nwokolo
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK; (R.P.A.); (C.N.)
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13
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Snook J, Bhala N, Beales ILP, Cannings D, Kightley C, Logan RP, Pritchard DM, Sidhu R, Surgenor S, Thomas W, Verma AM, Goddard AF. British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults. Gut 2021; 70:2030-2051. [PMID: 34497146 PMCID: PMC8515119 DOI: 10.1136/gutjnl-2021-325210] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022]
Abstract
Iron deficiency anaemia (IDA) is a major cause of morbidity and burden of disease worldwide. It can generally be diagnosed by blood testing and remedied by iron replacement therapy (IRT) using the oral or intravenous route. The many causes of iron deficiency include poor dietary intake and malabsorption of dietary iron, as well as a number of significant gastrointestinal (GI) pathologies. Because blood is iron-rich it can result from chronic blood loss, and this is a common mechanism underlying the development of IDA-for example, as a consequence of menstrual or GI blood loss.Approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract. Therefore optimal management of IDA requires IRT in combination with appropriate investigation to establish the underlying cause. Unexplained IDA in all at-risk individuals is an accepted indication for fast-track secondary care referral in the UK because GI malignancies can present in this way, often in the absence of specific symptoms. Bidirectional GI endoscopy is the standard diagnostic approach to examination of the upper and lower GI tract, though radiological scanning is an alternative in some situations for assessing the large bowel. In recurrent or refractory IDA, wireless capsule endoscopy plays an important role in assessment of the small bowel.IDA may present in primary care or across a range of specialties in secondary care, and because of this and the insidious nature of the condition it has not always been optimally managed despite the considerable burden of disease- with investigation sometimes being inappropriate, incorrectly timed or incomplete, and the role of IRT for symptom relief neglected. It is therefore important that contemporary guidelines for the management of IDA are available to all clinicians. This document is a revision of previous British Society of Gastroenterology guidelines, updated in the light of subsequent evidence and developments.
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Affiliation(s)
- Jonathon Snook
- Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Neeraj Bhala
- Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust and Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ian L P Beales
- Gastroenterology, University of East Anglia, Norwich, UK
| | - David Cannings
- Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Chris Kightley
- Digestive Diseases, Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | | | - D Mark Pritchard
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool and Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Reena Sidhu
- Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Sue Surgenor
- Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Wayne Thomas
- Haematology, Plymouth Hospitals NHS Foundation Trust, Plymouth, Plymouth, UK
| | - Ajay M Verma
- Digestive Diseases, Kettering General Hospital NHS Foundation Trust, Kettering, UK
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14
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Abdel-Maksoud M, Aly El-Gabry D, Al Kayoumi T, Alketbi J, Mohamednour D, Elhassan Elamin M, Subhash Reddy M, Al Yafei ZA, Stip E, Abdel Aziz K, Arnone D. Measures of gluten-related reactivity in children with autism spectrum disorders in the absence of overt gastrointestinal symptoms: a pilot study from the United Arab Emirates. J Int Med Res 2021; 48:300060520952655. [PMID: 32959707 PMCID: PMC7513412 DOI: 10.1177/0300060520952655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objectives The aetiology of autism spectrum disorder (ASD) is multifactorial, sometimes
genetic, and may be associated with abnormal immunological responses to
peptides from proteins such as gluten. These peptides may cross the
blood-brain barrier and affect neurotransmission, resulting in behavioural
symptoms consistent with ASD. The aim of this study was to screen for
markers of gluten-related immune reactivity in the absence of overt
gastrointestinal symptoms in patients with ASD in the United Arab Emirates,
a country associated with a high prevalence of ASD but lacking this type of
research. Methods Patients diagnosed with ASD (using Diagnostic and Statistical Manual of
Mental Disorders-IV-based criteria and Autism Diagnostic Observational
Schedules) were compared with controls, regarding anti-tissue
transglutaminase (tTG) immunoglobulin (Ig) A and anti-deamidated gliadin
peptide (DGP) IgA levels. Results Sixty-six patients with ASD and 101 controls were included. Patients with ASD
showed statistically significant lower anti-DGP IgA levels, but no
significant difference in anti-tTG IgA levels, versus healthy controls.
Correlations between immunological data and clinical symptoms were
synergistic, but not statistically significant. Conclusion ASD may be associated with reduced levels of anti-DGP IgA.
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Affiliation(s)
- Mohamed Abdel-Maksoud
- Department of Psychiatry, Maudsley Health, Al-Amal Psychiatric Hospital, Dubai, United Arab Emirates.,Department of Psychiatry, Ministry of Health and Prevention (MOHAP), Al-Amal Psychiatric Hospital, Dubai, United Arab Emirates
| | - Dina Aly El-Gabry
- Okasha Institute of Psychiatry, Neuropsychiatry Department, Ain Shams University, Cairo, Egypt
| | - Tahani Al Kayoumi
- Department of Psychiatry, Ministry of Health and Prevention (MOHAP), Al-Amal Psychiatric Hospital, Dubai, United Arab Emirates
| | - Jamila Alketbi
- Department of Psychiatry, Behavioural Science Institute, Al-Ain Hospital, Al-Ain, United Arab Emirates
| | - Duaa Mohamednour
- Erada Centre for Treatment and Rehabilitation, Dubai, United Arab Emirates
| | | | - Marri Subhash Reddy
- Department of Psychiatry, Behavioural Science Institute, Al-Ain Hospital, Al-Ain, United Arab Emirates
| | - Zain Ali Al Yafei
- Medical Laboratories Department, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Emmanuel Stip
- Department of Psychiatry and Behavioural Science, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Hospitalier Universitaire de Montreal (CHUM), Institut Universitaire en Santé Mentale de Montréal, Université de Montreal, Canada
| | - Karim Abdel Aziz
- Department of Psychiatry and Behavioural Science, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Danilo Arnone
- Department of Psychiatry and Behavioural Science, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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15
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Ebrahimi MP, Alimadadi H, Najafi M, Vasei M, Rahmani P. Investigation of Tissue Transglutaminase Antibody Normalization in Response to Gluten-Free Diet in Children with Celiac Disease. JOURNAL OF CHILD SCIENCE 2021. [DOI: 10.1055/s-0041-1724033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractA very limited amount of data are available regarding the follow-up of celiac disease (CD) treatment in Iran. The aim of this study is to investigate antitissue transglutaminase (atTG) normalization interval and the associated factors in CD patients. This retrospective study included CD patients enrolled in Children's Medical Center, Tehran University of Medical Sciences. The initial atTG titer and histological evaluation (with Marsh grade ≥2) were recorded. The atTG titer was assessed in each follow-up until the time of normalization where children were strictly on gluten-free diet. The age at the time of diagnosis, gender, Marsh grade at the time of diagnosis, other comorbidities, and family history of CD patients were recorded to determine the association of these factors with antibody normalization interval. In total, 71 patients were recruited in the study of which 34 (47.89%) subjects had atTG level below 20 U/mL at the average interval of 31.36 ( ± 2.89) months (95% confidence interval: 25.7–37.02). There was no significant difference between the antibody normalization interval and different age ranges and Marsh grade. Cox regression demonstrated that gender, age ranges, Marsh grade, positive family history of CD, and the presence of comorbidities did not significantly predict longer antibody normalization interval.
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Affiliation(s)
- Mohsen Pour Ebrahimi
- Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hosein Alimadadi
- Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehri Najafi
- Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Vasei
- Cell Therapies Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | - Parisa Rahmani
- Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
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16
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Alwasaidi TA, Mustafa W, Osman H, Al-Hebshi A, Alfetayeh A. Multiple Autoimmune Syndrome With Alopecia Universalis and Immune Thrombocytopenic Purpura. Cureus 2021; 13:e13033. [PMID: 33665054 PMCID: PMC7924964 DOI: 10.7759/cureus.13033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2021] [Indexed: 11/05/2022] Open
Abstract
Multiple autoimmune syndrome (MAS) is a condition characterized by three or more autoimmune disorders in the same individual. The development of MAS involves genetic, immunological, and infectious factors. Here we report a case of a 40-year-old man who presented with four autoimmune diseases, namely autoimmune hypothyroidism, alopecia universalis, celiac disease, and immune thrombocytopenic purpura (ITP), which leads to a diagnosis of MAS. However, the patient does not fit in any category of MAS classification. In addition to the need for continued surveillance for the development of new autoimmune disease in predisposed patients, this case report suggests an additional fourth category of the classification of MAS that includes autoimmune hypothyroidism, alopecia universalis, celiac disease, and ITP.
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Affiliation(s)
- Turki A Alwasaidi
- Hematology Division/Internal Medicine Department, Prince Mohammed Bin Abdulaziz Hospital - Ministry of National Guard Health Affairs, Madinah, SAU
- Internal Medicine, Taibah University, Madinah, SAU
| | | | - Haitham Osman
- Hematology Division/Internal Medicine Department, Prince Mohammed Bin Abdulaziz Hospital - Ministry of National Guard Health Affairs, Madinah, SAU
| | - Abdulqader Al-Hebshi
- Pediatrics-Hematology Oncology, Prince Mohammed Bin Abdulaziz Hospital, Madinah, SAU
- Pediatrics, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Asma Alfetayeh
- Hematology, Prince Mohammed Bin Abdulaziz Hospital, Madinah, SAU
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17
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Ziv-Baran T, Dubov Y, Weinberger R, Guz-Mark A, Shamir R, Assa A. Anti-tissue transglutaminase titers are associated with endoscopic findings and severity of mucosal damage in children with celiac disease. Eur J Pediatr 2021; 180:263-269. [PMID: 32772154 DOI: 10.1007/s00431-020-03770-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
We aimed to assess the correlation between clinical findings, serology, endoscopic findings, and histology in children diagnosed with celiac disease. Medical records of children diagnosed with celiac disease (2010-2017) at the Schneider Children's Hospital were reviewed retrospectively. Correlation between serologic measures anti-tissue transglutaminase (anti-tTG)/anti-endomysial antibodies (EMA) and other variables including mucosal damage, endoscopic findings (scalloping of duodenal folds), and clinical findings (abdominal pain, diarrhea, and anemia) was assessed. Out of 686 patients, 432 patients fulfilled the inclusion criteria (females 262, 61%; median age 6.0; interquartile range 4.0-9.0 years). Distribution of histopathology findings was Marsh IIIa 4%, Marsh IIIb 25%, and Marsh IIIc 71% with 313 (73%) patients having anti-tTG titer of ≥ 10 times the upper normal limit. Anti-tTG titer (but not EMA) positively correlated with Marsh grades, scalloping of duodenal folds and anemia. Anti-tTG ≥ 10 times the upper normal limit was associated with Marsh IIIc changes with an adjusted odds ratio of 4.5 (95% confidence interval, 1.7-12.1). Diarrhea and abdominal pain were not associated with serologic, endoscopic, or histologic markers of disease severity.Conclusion: Anti-tTG titers correlated with macroscopic and microscopic mucosal damage, with anemia but not with diarrhea or abdominal pain in children with celiac disease. What is Known: • Tissue transglutaminase antibody titers were shown to correlate with the degree of mucosal damage in patients with celiac disease. • There is a limited evidence regarding the association of celiac serologies with endoscopic and clinical measures. What is New: • Higher titers of tissue transglutaminase but not anti-endomysial antibodies are associated with more severe histologic and endoscopic damage and with the presence of anemia. • Symptoms do not correlate with the severity of mucosal damage such as scalloping of duodenal folds and histopathology changes according to Marsh classification or with serologic markers.
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Affiliation(s)
- Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yulia Dubov
- Immunology Laboratory, Clalit Health Services, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Anat Guz-Mark
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, 14 Kaplan St., 4920235, Petah Tikva, Israel
| | - Raanan Shamir
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, 14 Kaplan St., 4920235, Petah Tikva, Israel
| | - Amit Assa
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. .,Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, 14 Kaplan St., 4920235, Petah Tikva, Israel.
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Thompson G, Grover Z, Loh R, Mews C, Ravikumara M, Jevon G, D'Orsogna L, McLean-Tooke A. Assessment of European Society of Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines in an Australian paediatric population. Pathology 2020; 52:568-575. [PMID: 32586687 DOI: 10.1016/j.pathol.2020.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 12/20/2022]
Abstract
Coeliac disease (CD) diagnosis is based on clinical assessment, detection of specific autoantibodies and histological examination of small intestinal biopsies. The European Society of Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines have recently been updated and recommend CD may be diagnosed without a biopsy or HLA typing in symptomatic patients with high titre IgA tissue transglutaminase antibodies (aTTG) and positive endomysial antibodies (EMA). However, the need for EMA in patients with high level aTTG has been questioned. We aimed to determine the diagnostic benefit of HLA typing, EMA and IgG antibodies to deamidated gliadin (DGP) in children with high level aTTG. We prospectively evaluated children presenting for assessment of possible CD. All patients underwent small bowel biopsy, serological testing and HLA typing. Results were analysed and correlated with histopathological diagnosis. A total of 209 children were assessed; 61.5% were found to have CD and 29% could have avoided biopsy as per 2020 ESPGHAN guidelines. Titres of aTTG ≥60 U/mL or DGP ≥28 U/mL gave 100% specificity and 100% positive predictive value (PPV) for CD. HLA typing and EMA did not improve the PPV of patients with aTTG ≥60 U/mL, but addition of DGP ≥28 U/mL improved diagnostic sensitivity whilst retaining 100% specificity. Addition of HLA and EMA testing in patients with high titre aTTG antibodies does not improve diagnostic performance and may possibly be omitted from the serological workup in these patients. Our data support combining aTTG and DGP testing and optimising cut-offs to maximise specificity as an alternative biopsy-free diagnostic approach.
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Affiliation(s)
- Grace Thompson
- Department of Clinical Immunology, PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | - Zubin Grover
- Department of Gastroenterology, Perth Children's Hospital, Perth, WA, Australia
| | - Richard Loh
- Department of Clinical Immunology, PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Catherine Mews
- Department of Gastroenterology, Perth Children's Hospital, Perth, WA, Australia
| | - Madhur Ravikumara
- Department of Gastroenterology, Perth Children's Hospital, Perth, WA, Australia
| | - Gareth Jevon
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Perth Children's Hospital, Perth, WA, Australia
| | - Lloyd D'Orsogna
- Department of Clinical Immunology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Andrew McLean-Tooke
- Department of Clinical Immunology, PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia; Department of Immunology, Perth Children's Hospital, Perth, WA, Australia
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19
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Trend of Antitissue Transglutaminase Antibody Normalization in Children With Celiac Disease Started on Gluten-free Diet: A Comparative Study Between Chemiluminescence and ELISA Serum Assays. J Pediatr Gastroenterol Nutr 2020; 70:37-41. [PMID: 31599818 DOI: 10.1097/mpg.0000000000002519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of this study is to compare the performance of antitissue transglutaminase (atTG) chemiluminescence immunoassay (CLIA) with the standard enzyme-linked immunosorbent assay (ELISA) methods in monitoring celiac children after the start of gluten-free diet (GFD). METHODS Celiac children diagnosed between 2005 and 2016 at our centre were classified into 2 groups based on serum assay (ELISA vs CLIA) used for atTG monitoring, and were compared on percentage of decrease and time to normalization of atTG on GFD. RESULTS Among 260 included children, the rate of normalization of atTG levels at 30 months' follow-up was 86% and 70% in ELISA and CLIA group, respectively (P < 0.01). Median time to normalization was 11.7 and 14.7 months in ELISA and CLIA group respectively (P = 0.003). Marsh score at diagnosis was not associated with time to atTG normalization (P = 0.770), whereas older age at diagnosis and higher baseline atTG predicted longer time to atTG normalization (P = 0.01, P < 0.01). CONCLUSIONS The percentage and the time of the atTG normalization in celiac children on GFD should be interpreted according to the utilized assay: at 30 months' follow-up children tested by CLIA are less likely to normalize atTG levels compared to those tested by ELISA. Younger age at diagnosis and lower baseline atTG are predictors of earlier atTG normalization, regardless of the adopted assay.
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Nellikkal SS, Hafed Y, Larson JJ, Murray JA, Absah I. High Prevalence of Celiac Disease Among Screened First-Degree Relatives. Mayo Clin Proc 2019; 94:1807-1813. [PMID: 31447136 DOI: 10.1016/j.mayocp.2019.03.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/24/2019] [Accepted: 03/04/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To investigate the prevalence of first-degree relatives (FDRs) with celiac disease detected at screening and diagnostic significance of anti-tissue transglutaminase (anti-TTG). PATIENTS AND METHODS We performed a retrospective cohort study of 104 patients with a diagnosis of celiac disease and their FDRs, collecting data from electronic records of Mayo Clinic and celiac disease registry from December 20, 1983, to May 22, 2017. We collected demographics, presenting symptoms, indication for testing, family history, number of other family members screened, biopsy reports, and results of serologic tests. RESULTS Of 477 FDRs identified, 360 were screened (mean screening rate per family, 79%±25%) and 160 FDRs (44.4%) were diagnosed with celiac disease, at a mean age 31.9±21.6 years (62% female). All diagnosed FDRs had positive anti-TTG titers. Clinical features were documented in 148 diagnosed FDRs, of those 9 (6%) had classic, 97 (66%) had non-classic symptoms, and 42(28%) had no reported symptoms. Histology reports were available from 155 FDRs: 12 (8%) had Marsh 1, 77 (50%) had Marsh 3a, and 66 (43%) had Marsh 3b. A level of anti-TTG greater than or equal to 2.75 of the upper limit of normal identified FDRs with villous atrophy with 87% sensitivity, 82% specificity, and a positive predictive value of 95%. CONCLUSION In a retrospective cohort study of patients diagnosed with celiac disease, we found a high prevalence of celiac disease among screened FDRs. High anti-TTG titers associated with villous atrophy on small bowel biopsies, irrespective of symptoms.
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Affiliation(s)
- Shilpa S Nellikkal
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yamen Hafed
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Joseph J Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Imad Absah
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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21
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Cabanillas B. Gluten-related disorders: Celiac disease, wheat allergy, and nonceliac gluten sensitivity. Crit Rev Food Sci Nutr 2019; 60:2606-2621. [PMID: 31402697 DOI: 10.1080/10408398.2019.1651689] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The consumption of gluten-free products is becoming an increased alimentary habit in the general population. The scientific unfounded perception suggesting that the avoidance of gluten would improve health or that gluten could be toxic for humans are fostering medically unjustified adherences to a gluten-free diet. Currently, only patients diagnosed with celiac disease are advised to follow a strict lifelong gluten-free diet. In the same way, patients diagnosed with IgE-mediated wheat allergy must avoid exposure to wheat in any form. In that context, a third disorder, called nonceliac gluten sensitivity, characterized by distress after gluten consumption and in which neither celiac disease nor IgE-mediated allergy plays a role, has gained increased attention in the last years. Although important scientific advances have been made in the understanding of the pathologic mechanisms behind nonceliac gluten sensitivity, this disorder is still a matter of active debate in the scientific community. In the present review, the most recent advances in the immunopathology, diagnostic biomarkers and susceptibility determinants of gluten-related diseases are summarized and discussed. Furthermore, an updated overview of the new potential therapies that are currently underway for the treatment of gluten-related disorders is also provided.
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Affiliation(s)
- Beatriz Cabanillas
- Department of Dermatology and Allergy, University of Bonn Medical Center, Bonn, Germany
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22
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Walker MD, Zylberberg HM, Green PHR, Katz MS. Endocrine complications of celiac disease: a case report and review of the literature. Endocr Res 2019; 44:27-45. [PMID: 30198791 DOI: 10.1080/07435800.2018.1509868] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this article is to review recent literature regarding endocrine disorders related to celiac disease (CD). METHODS We describe a case report and review existing literature on the endocrine manifestations of CD. RESULTS CD is an autoimmune disorder characterized by intestinal inflammation in response to gluten. CD can cause a wide range of extra-intestinal complications, including endocrine manifestations. Metabolic bone disease including osteoporosis and osteopenia, vitamin D deficiency, secondary hyperparathyroidism and less frequently osteomalacia can be seen. In CD, fracture risk is increased by 30-40%, while risk for hip fracture is approximately doubled. The risk for other endocrine disorders, particularly autoimmune endocrinopathies, is also increased in those with CD compared to the general population. Epidemiologic data indicate the risk for hypothyroidism is 3-4 times higher among those with CD, while risk of type 1 diabetes is greater than double. Risk for primary adrenal insufficiency is a striking 11-fold higher in those with versus without CD, though the absolute risk is low. Fertility is reduced in women with CD before diagnosis by 37% while male fertility in the absence of hypogonadism does not appear to be affected. Other endocrine conditions including hyperthyroidism, ovarian failure, androgen insensitivity, impaired growth and growth hormone deficiency and autoimmune polyendocrine syndromes have also been associated with CD. CONCLUSIONS CD is associated with a wide range of endocrine manifestations.
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Affiliation(s)
- Marcella D Walker
- a Department of Medicine , Columbia University , New York , NY , USA
| | | | - Peter H R Green
- a Department of Medicine , Columbia University , New York , NY , USA
| | - Michael S Katz
- c Department of Medicine , University of Texas Health Science Center at San Antonio , San Antonio , TX , USA
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23
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Choung RS, Khaleghi Rostamkolaei S, Ju JM, Marietta EV, Van Dyke CT, Rajasekaran JJ, Jayaraman V, Wang T, Bei K, Rajasekaran KE, Krishna K, Krishnamurthy HK, Murray JA. Synthetic Neoepitopes of the Transglutaminase-Deamidated Gliadin Complex as Biomarkers for Diagnosing and Monitoring Celiac Disease. Gastroenterology 2019; 156:582-591.e1. [PMID: 30342033 DOI: 10.1053/j.gastro.2018.10.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 09/21/2018] [Accepted: 10/09/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Celiac disease (CeD) has characteristics of an autoimmune disease, such as increased antibody levels to tissue transglutaminase (tTG). However, assays to measure these biomarkers in blood samples do not identify patients with sufficient accuracy for diagnosis or monitoring of CeD. We aimed to discover biomarkers of CeD derived from neoepitopes of deamidated gliadin peptides (DGP) and tTG fragments and to determine if immune reactivity against these epitopes can identify patients with CeD with mucosal healing. METHODS We analyzed serum samples from 90 patients with biopsy-proven CeD and 79 healthy individuals (controls) for immune reactivity against the tTG-DGP complex (discovery cohort). A fluorescent peptide microarray platform was used to estimate the antibody-binding intensity of each synthesized tTG-DGP epitope. We validated our findings in 82 patients with newly diagnosed CeD and 217 controls. We tested the ability of our peptide panel to identify patients with mucosal healing (based on the histologic analysis) using serum samples from patients with treated and healed CeD (n = 85), patients with treated but unhealed CeD (n = 81; villous atrophy despite a adhering a gluten-free diet), patients with untreated CeD (n = 82) and disease controls (n = 27), villous atrophy without CeD), and healthy controls (n = 217). Data were analyzed using principal component analysis followed by machine learning and support vector machine modeling. RESULTS We identified 172 immunogenic epitopes of the tTG-DGP complex. We found significantly increased immune reactivity against these epitopes vs controls. In the both cohort, the set of neoepitopes derived from the tTG-DGP complex identified patients with CeD with 99% sensitivity and 100% specificity. Serum samples from patients with untreated CeD had the greatest mean antibody-binding intensity against the tTG-DGP complex (32.5 ± 16.4). The average antibody-binding intensity was significantly higher in serum from patients with treated but unhealed CeD mucosa (15.1 ± 7.5) than in patients with treated and healed CeD mucosa (5.5 ± 3.4) (P < .001). The assay identified patients with mucosa healing status with 84% sensitivity and 95% specificity. CONCLUSIONS We identified immunogenic epitopes of the tTG-DGP complex, and found that an assay to measure the immune response to epitopes accurately identified patients with CeD, as well as patients with mucosal healing. This biomarker assay might be used in detection and monitoring of patients with CeD.
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Affiliation(s)
- Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Josephine M Ju
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Eric V Marietta
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Carol T Van Dyke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Kang Bei
- Vibrant Sciences LLC, San Carlos, California
| | | | | | | | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Abstract
Coeliac disease (CD) is an autoimmune gastrointestinal disorder whereby the ingestion of gluten, a storage protein found in wheat, barley and rye, causes damage to intestinal mucosa with resultant malabsorption, increased risk of anaemia and osteoporosis. Worldwide estimates suggest 1% of the population have CD. With no cure, the only treatment is a gluten-free diet (GFD). Adhering to a GFD can be very challenging; it requires knowledge, motivation and modified behaviours. Assessing adherence to a GFD is methodologically challenging. This review aims to provide an overview of the literature reporting adherence to a GFD in people with CD and the methodological challenges encountered. From six studies it has been reported that rates of adherence to a GFD range between 45 and 90% in patients of different ethnicities with CD. GF dietary adherence can be influenced by age at diagnosis, coexisting depression, symptoms on ingestion of gluten, nutrition counselling, knowledge of GF foods, understanding of food labels, cost and availability of GF foods, receiving GF foods on prescription and membership of a coeliac society. To date only five intervention studies in adults with CD have been undertaken to improve GF dietary adherence. These have included dietary and psychological counselling, and the use of online training programmes, apps, text messages and telephonic clinics. Future interventions should include people of all ethnicities, consider patient convenience and the cost-effectiveness for the healthcare environment.
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25
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Zylberberg HM, Lebwohl B, Green PHR. Celiac Disease-Musculoskeletal Manifestations and Mechanisms in Children to Adults. Curr Osteoporos Rep 2018; 16:754-762. [PMID: 30350261 DOI: 10.1007/s11914-018-0488-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW We aim to review the current literature on the association of musculoskeletal disorders and celiac disease that is a common disorder, affecting about 1% of the population. Extra-intestinal symptoms and presentations predominate. RECENT FINDINGS While the literature supports an association with reduced bone mineral density and increased fracture risk and celiac disease, there is little evidence supporting associations with other rheumatological conditions. Patients frequently report musculoskeletal symptoms; however, studies of specific disease entities suffer from a lack of standardization of testing for celiac disease and a lack of control groups. Well-controlled, preferably population-based studies are required to further explore a relationship between celiac disease and musculoskeletal disorders.
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Affiliation(s)
- Haley M Zylberberg
- Celiac Disease Center, Columbia University Medical Center, 180 Fort Washington Ave, New York, NY, 10032, USA
| | - Benjamin Lebwohl
- Celiac Disease Center, Columbia University Medical Center, 180 Fort Washington Ave, New York, NY, 10032, USA
| | - Peter H R Green
- Celiac Disease Center, Columbia University Medical Center, 180 Fort Washington Ave, New York, NY, 10032, USA.
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26
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Chetcuti Zammit S, Sanders DS, Sidhu R. A comprehensive review on the utility of capsule endoscopy in coeliac disease: From computational analysis to the bedside. Comput Biol Med 2018; 102:300-314. [PMID: 29980284 DOI: 10.1016/j.compbiomed.2018.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/23/2018] [Accepted: 06/24/2018] [Indexed: 11/29/2022]
Abstract
Small bowel capsule endoscopy (SBCE) can identify macroscopic changes of coeliac disease and assess the extent of disease in the small bowel beyond the duodenum. SBCE has a good sensitivity for the detection of coeliac disease in comparison to histology owing to several ideal features such as a high magnification. It also plays a useful role in detecting complications in patients with refractory coeliac disease. Several studies have been carried out on transforming images obtained from small bowel capsule endoscopy to enable the automated detection of features related to coeliac disease. This review discusses the current roles played by small bowel capsule endoscopy in coeliac disease. It identifies future potential roles of this technique and describes in great detail the role of computational analysis in the detection of coeliac disease and how it can be adapted to current available technology.
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Affiliation(s)
- Stefania Chetcuti Zammit
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK.
| | - David S Sanders
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
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27
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Can High Titres of Anti Tissue Transglutaminase Antibodies Reduce the Need for Intestinal Biopsy for Diagnosis of Celiac Disease? Indian J Clin Biochem 2018; 33:456-460. [PMID: 30319193 DOI: 10.1007/s12291-017-0695-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 09/07/2017] [Indexed: 01/15/2023]
Abstract
Traditionally small intestinal biopsy has been considered a gold standard for the diagnosis of celiac disease (CD). But now data has shown that serological markers like anti-tissue-transglutaminase antibodies (tTGA) can be used to make the diagnosis with great sensitivity and specificity. The objective of the present study was to evaluate whether patients with high probability of CD and high titre of tTGA, have a high probability of intestinal damage and may not require biopsy for final diagnosis. All the cases with tTGA levels ≥15 IU/ml and who subsequently underwent biopsy from July 2010 to June 2013 were selected. Histopathological findings graded as per Marsh classification were correlated with serum tTGA levels. Grade 3 lesions were considered diagnostic for the disease. Out of total 731 patients 470 had serum tTGA levels >100 IU/ml and 261 patients had <100 IU/ml. Highest levels of tTGA (219.3 IU/ml) were seen in grade 3c which was >12 times the normal cutoff value. Mean serum tTGA in higher histological grade i.e. 3 (3a, 3b, 3c) was 186.7 IU/ml (>12 times the normal cut off value) as compared to grade 1 which was 108.9 IU/ml (>7 times the normal cut off value). Using a tTGA cutoff value of 70 IU/ml, sensitivity was found to be 83.9% while specificity was 56.10% with an overall accuracy of 77.7%. This study confirms that a small intestinal biopsy is not always necessary for the diagnosis of CD in symptomatic patients with high tTGA levels (>70 IU/ml).
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28
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Remes-Troche JM, Uscanga-Domínguez LF, Aceves-Tavares RG, Calderón de la Barca AM, Carmona-Sánchez RI, Cerda-Contreras E, Coss-Adame E, Icaza-Chávez ME, Lopéz-Colombo A, Milke-García MP, Morales-Arámbula M, Peláez-Luna M, Ramos Martínez P, Sánchez-Sosa S, Treviño-Mejía MC, Vázquez-Frías R, Worona-Dibner LB, Zamora-Nava LE, Rubio-Tapia A. Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2018; 83:434-450. [PMID: 30197183 DOI: 10.1016/j.rgmx.2018.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/12/2018] [Accepted: 05/24/2018] [Indexed: 12/17/2022]
Abstract
Celiac disease, celiac sprue, or gluten-sensitive enteropathy, is a generalized autoimmune disease characterized by chronic inflammation and atrophy of the small bowel mucosa. It is caused by dietary exposure to gluten and affects genetically predisposed individuals. In Mexico, at least 800,000 are estimated to possibly have the disease, prompting the Asociación Mexicana de Gastroenterología to summon a multidisciplinary group of experts to develop the "Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico" and establish recommendations for the medical community, its patients, and the general population. The participating medical professionals were divided into three working groups and were given the selected bibliographic material by the coordinators (ART, LUD, JMRT), who proposed the statements that were discussed and voted upon in three sessions: two voting rounds were carried out electronically and one at a face-to-face meeting. Thirty-nine statements were accepted, and once approved, were developed and revised by the coordinators, and their final version was approved by all the participants. It was emphasized in the document that epidemiology and risk factors associated with celiac disease (first-degree relatives, autoimmune diseases, high-risk populations) in Mexico are similar to those described in other parts of the world. Standards for diagnosing the disease and its appropriate treatment in the Mexican patient were established. The guidelines also highlighted the fact that a strict gluten-free diet is essential only in persons with confirmed celiac disease, and that the role of gluten is still a subject of debate in relation to nonceliac, gluten-sensitive patients.
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Affiliation(s)
- J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, México.
| | - L F Uscanga-Domínguez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - R G Aceves-Tavares
- Servicio de Gastroenterología, Hospital General del Estado Dr. Ernesto Ramos, Bours, Hermosillo, Sonora, México
| | | | | | - E Cerda-Contreras
- ITESM. Medicina Interna y Gastroenterología Fundación Clínica Médica Sur, Ciudad de México, México
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Ciudad de México, México
| | - M E Icaza-Chávez
- Hospital Star Médica de Mérida, Gastroenterología de la UNIMAYAB, , Mérida, Yucatán, México
| | - A Lopéz-Colombo
- Dirección de Educación e Investigación en Salud, UMAE Hospital de Especialidades del Centro Médico Nacional Manuel Ávila Camacho, Instituto Mexicano del Seguro Social, Puebla, México
| | - M P Milke-García
- Dirección de Nutrición, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Ciudad de México, México
| | - M Morales-Arámbula
- Servicio de Gastroenterología y Endoscopía Gastrointestinal, Hospital Country 2000, Guadalajara, Jalisco, México
| | - M Peláez-Luna
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | | | - S Sánchez-Sosa
- Jefe de Patología, Hospital Ángeles de Puebla, Universidad de Las Américas Puebla (UDLAP), Puebla, México
| | - M C Treviño-Mejía
- Universidad Iberoamericana, Universidad Xochicalco, Tijuana, Baja California, México
| | - R Vázquez-Frías
- Universidad Iberoamericana, Universidad Xochicalco, Tijuana, Baja California, México
| | - L B Worona-Dibner
- Departamento de Gastroenterología y Nutrición, Hospital Infantil de México Federico Gómez, Ciudad de México, México
| | - L E Zamora-Nava
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - A Rubio-Tapia
- División de Gastroenterología y Hepatología, Mayo Clinic, Rochester, Minnesota, Estados Unidos de América
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Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2018.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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30
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Chetcuti Zammit S, Sanders DS, Sidhu R. Capsule endoscopy for patients with coeliac disease. Expert Rev Gastroenterol Hepatol 2018; 12:779-790. [PMID: 29886766 DOI: 10.1080/17474124.2018.1487289] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Coeliac disease is an autoimmune mediated condition in response to gluten. A combination of innate and adaptive immune responses results in villous shortening in the small bowel (SB) that can be morphologically picked up on capsule endoscopy. It is the only imaging modality that can provide mucosal views of the entire SB, while histology is generally limited to the proximal SB. Radiological modalities are not designed to pick up changes in villous morphology. Areas covered: In this review, we provide a comprehensive analysis on the justified use of small bowel capsule endoscopy (SBCE) in the assessment of patients with coeliac disease; compare SBCE to histology, serology, and symptomatology; and provide an overview on automated quantitative analysis for the detection of coeliac disease. We also provide insight into future work on SBCE in relation to coeliac disease. Expert commentary: SBCE has opened up new avenues for the diagnosis and monitoring of patients with coeliac disease. However, larger studies with new and established coeliac disease patients and with greater emphasis on morphological features on SBCE are required to better define the role of SBCE in the setting of coeliac disease.
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Affiliation(s)
| | - David S Sanders
- a Gastroenterology Department , Sheffield Teaching Hospitals , Sheffield , UK
| | - Reena Sidhu
- a Gastroenterology Department , Sheffield Teaching Hospitals , Sheffield , UK
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Ludvigsson JF, Ciacci C, Green PH, Kaukinen K, Korponay-Szabo IR, Kurppa K, Murray JA, Lundin KEA, Maki MJ, Popp A, Reilly NR, Rodriguez-Herrera A, Sanders DS, Schuppan D, Sleet S, Taavela J, Voorhees K, Walker MM, Leffler DA. Outcome measures in coeliac disease trials: the Tampere recommendations. Gut 2018; 67:1410-1424. [PMID: 29440464 PMCID: PMC6204961 DOI: 10.1136/gutjnl-2017-314853] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 12/19/2017] [Accepted: 01/08/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE A gluten-free diet is the only treatment option of coeliac disease, but recently an increasing number of trials have begun to explore alternative treatment strategies. We aimed to review the literature on coeliac disease therapeutic trials and issue recommendations for outcome measures. DESIGN Based on a literature review of 10 062 references, we (17 researchers and 2 patient representatives from 10 countries) reviewed the use and suitability of both clinical and non-clinical outcome measures. We then made expert-based recommendations for use of these outcomes in coeliac disease trials and identified areas where research is needed. RESULTS We comment on the use of histology, serology, clinical outcome assessment (including patient-reported outcomes), quality of life and immunological tools including gluten immunogenic peptides for trials in coeliac disease. CONCLUSION Careful evaluation and reporting of outcome measures will increase transparency and comparability of coeliac disease therapeutic trials, and will benefit patients, healthcare and the pharmaceutical industry.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Carolina Ciacci
- Coeliac Center at Department of Medicine and Surgery, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Peter Hr Green
- Celiac Disease Center at Columbia University, New York, USA
| | - Katri Kaukinen
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Ilma R Korponay-Szabo
- Coeliac Disease Centre, Heim Pál Children's Hospital, Budapest, Hungary
- Department of Paediatrics, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Kalle Kurppa
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | | | - Knut Erik Aslaksen Lundin
- Institute of Clinical Medicine and K.G. Jebsen Coeliac Disease Research Centre, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Markku J Maki
- Science Center, Tampere University Hospital, Tampere, Finland
- Tampere Centre for Child Health Research, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Alina Popp
- Institute for Mother and Child Health Bucharest, University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania
- Tampere Centre for Child Health Research, University of Tampere, Tampere University Hospital, Tampere, Finland
| | - Norelle R Reilly
- Division of Pediatric Gastroenterology, Columbia University Medical Center, New York, USA
- Celiac Disease Center, Department of Medicine, Columbia University Medical Center, New York, USA
| | | | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Detlef Schuppan
- Celiac Center, University Medical Center, Johannes-Gutenberg University, Mainz, Germany
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Juha Taavela
- Tampere Centre for Child Health Research, University of Tampere, Tampere University Hospital, Tampere, Finland
| | | | - Marjorie M Walker
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Daniel A Leffler
- Celiac Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Coeliac disease occurs in about 1% of people in most populations. Diagnosis rates are increasing, and this seems to be due to a true rise in incidence rather than increased awareness and detection. Coeliac disease develops in genetically susceptible individuals who, in response to unknown environmental factors, develop an immune response that is subsequently triggered by the ingestion of gluten. The disease has many clinical manifestations, ranging from severe malabsorption to minimally symptomatic or non-symptomatic presentations. Diagnosis requires the presence of duodenal villous atrophy, and most patients have circulating antibodies against tissue transglutaminase; in children, European guidelines allow a diagnosis without a duodenal biopsy provided that strict symptomatic and serological criteria are met. Although a gluten-free diet is an effective treatment in most individuals, a substantial minority develop persistent or recurrent symptoms. Difficulties adhering to a gluten-free diet have led to the development of non-dietary therapies, several of which are undergoing trials in human beings.
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Affiliation(s)
- Benjamin Lebwohl
- Celiac Disease Center, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital & University of Sheffield, UK
| | - Peter H R Green
- Celiac Disease Center, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, USA.
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Abstract
Coeliac disease is increasingly recognized as a global problem in both children and adults. Traditionally, the findings of characteristic changes of villous atrophy and increased intraepithelial lymphocytosis identified in duodenal biopsy samples taken during upper gastrointestinal endoscopy have been required for diagnosis. Although biopsies remain advised as necessary for the diagnosis of coeliac disease in adults, European guidelines for children provide a biopsy-sparing diagnostic pathway. This approach has been enabled by the high specificity and sensitivity of serological testing. However, these guidelines are not universally accepted. In this Perspective, we discuss the pros and cons of a biopsy-avoiding pathway for the diagnosis of coeliac disease, especially in this current era of the call for more biopsies, even from the duodenal bulb, in the diagnosis of coeliac disease. In addition, a contrast between paediatric and adult guidelines is presented.
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Mass Screening for Celiac Disease Among School-aged Children: Toward Exploring Celiac Iceberg in Saudi Arabia. J Pediatr Gastroenterol Nutr 2017; 65:646-651. [PMID: 28753180 DOI: 10.1097/mpg.0000000000001681] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES We conducted this mass screening study to determine the prevalence of celiac disease (CD) and characterize the celiac iceberg among Saudi pediatric population in Riyadh, the capital city of Saudi Arabia. METHODS During the study period (January 2014-June 2016), we have conducted a cross-sectional, mass screening, immunoglobulin A-tissue transglutaminase (TTG-IgA)-based study on 7930 Saudi students from primary and intermediate schools in Riyadh. Students with positive TTG-IgA (>20 U/L) were called in the hospital to undergo a repeat of TTG-IgA; in those with borderline positive TTG-IgA (20-60 U/L), IgA-endomyseal antibody (EMA-IgA) test was performed. Children with TTG-IgA >60 U/L and children with borderline positive TTG-IgA and positive EMA-IgA were advised to undergo upper endoscopy and intestinal biopsies. RESULTS We identified 221 students with positive TTG-IgA (2.8%). CD was diagnosed in 119 cases (1.5%, 1:67 Saudi children) (mean age 11.5 ± 2.62 years; girls 81 [68%]). Another 51 children had persistently borderline positive TTG-IgA but negative EMA (0.64%) and the remaining 51 had transiently positive TTG-IgA. We have identified 3 clinical patterns in the screening-identified cases with CD: a silent form (37%), a mild symptomatic form characterized by gastrointestinal symptoms in presence of normal growth or overweight/obesity (48%), and gastrointestinal symptoms associated with impaired growth in 15%. CONCLUSIONS Our study provided evidence of a high prevalence of CD among Saudi children (1.5%), a rate that is at least twice the average prevalence rate in Europe and North America.
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The Role of an IgA/IgG-Deamidated Gliadin Peptide Point-of-Care Test in Predicting Persistent Villous Atrophy in Patients With Celiac Disease on a Gluten-Free Diet. Am J Gastroenterol 2017; 112:1859-1867. [PMID: 29016564 DOI: 10.1038/ajg.2017.357] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/05/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Mucosal healing is important in celiac disease (CD) for the prevention of complications. However, obtaining duodenal biopsies is invasive, and there is currently no reliable surrogate marker for histological remission in clinical practice. We aimed to assess the role of a point-of-care test (POCT) based on IgA/IgG-deamidated gliadin peptide, in detecting persistent villous atrophy (VA) in CD. METHODS We prospectively recruited patients with CD attending endoscopy for the assessment of histological remission. All patients had IgA-endomysial (EMA) antibodies, IgA-tissue transglutaminase (TTG) antibodies, and the POCT performed, and completed a validated dietary adherence questionnaire. A gastroscopy was performed in all patients, with four biopsies taken from the second part of the duodenum and one from the duodenal bulb. We compared the diagnostic performance of the surrogate markers against duodenal histology as the reference standard. RESULTS A total of 217 patients with CD (70% female, age range 16-83 years, median age 53 years) on a gluten-free diet (median duration 6 years) were recruited from 2013 to 2017. Eighty-five (39.2%) patients had persistent VA. The sensitivities of the POCT, TTG, EMA, and the adherence score in detecting VA were 67.1%, 44.7%, 37.7%, and 24.7% respectively (P=0.0005). The combination of the POCT and adherence score only marginally increased the sensitivity to 70.6% (59.7-80.0%). CONCLUSIONS The sensitivity of the POCT was higher than the other surrogate markers in predicting VA. A POCT may provide the additional advantage of an immediate objective assessment of mucosal healing at the time of an office-based follow-up consultation.
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Szakács Z, Mátrai P, Hegyi P, Szabó I, Vincze Á, Balaskó M, Mosdósi B, Sarlós P, Simon M, Márta K, Mikó A, Pécsi D, Demcsák A, Bajor J. Younger age at diagnosis predisposes to mucosal recovery in celiac disease on a gluten-free diet: A meta-analysis. PLoS One 2017; 12:e0187526. [PMID: 29095937 PMCID: PMC5695627 DOI: 10.1371/journal.pone.0187526] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/27/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Persistent intestinal damage is associated with higher complication rates in celiac disease. We aimed to assess the potential modifiers of mucosal recovery. MATERIALS AND METHODS We screened databases (PubMed, Embase, Cochrane Trials, and Web of Science) for papers on celiac disease. Papers discussing (1) celiac patients (2) follow-up biopsy and (3) mucosal recovery after commencement of a gluten-free diet were included. The primary outcome was to produce a comprehensive analysis of complete mucosal recovery (i.e., Marsh 0 on follow-up). We compared children's recovery ratios to those of adults. Patients following a strict gluten-free dietary regimen were included in a subgroup. Summary point estimates, 95% confidence intervals (CIs), and 95% predictive intervals (PIs) were calculated. Heterogeneity was tested with I2-statistic. The PROSPERO registration number is CRD42016053482. RESULTS The overall complete mucosal recovery ratio, calculated from 37 observational studies, was 0.36 (CI: 0.28-0.44, PI: -0.12-0.84; I2: 98.4%, p<0.01). Children showed higher complete mucosal recovery ratio than adults (p<0.01): 0.65 (CI: 0.44-0.85, PI: -0.10-1.39; I2: 96.5%, p<0.01) as opposed to 0.24 (CI: 0.15-0.33, PI: -0.19-1.08; I2: 96.3%, p<0.01). In the strict dietary adherence subgroup, complete mucosal recovery ratio was 0.47 (CI: 0.24-0.70, PI: -0.47-1.41; I2: 98.8%, p<0.001). On meta-regression, diagnostic villous atrophy (Marsh 3) ratio (-8.97, p<0.01) and male ratio (+6.04, p<0.01) proved to be a significant determinant of complete mucosal recovery, unlike duration of gluten-free diet (+0.01, p = 0.62). The correlation between complete mucosal recovery ratio and age on diagnosis is of borderline significance (-0.03, p = 0.05). CONCLUSIONS There is considerable heterogeneity across studies concerning complete mucosal recovery ratios achieved by a gluten-free diet in celiac disease. Several celiac patients fail to achieve complete mucosal recovery even if a strict dietary regimen is followed. Younger age on diagnosis, less severe initial histologic damage and male gender predispose for achieving mucosal recovery.
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Affiliation(s)
- Zsolt Szakács
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Péter Mátrai
- Institute of Bioanalysis, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
- Hungarian Academy of Sciences-University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary
| | - Imre Szabó
- Division of Gastroenterology, 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Áron Vincze
- Division of Gastroenterology, 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Márta Balaskó
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | | | - Patrícia Sarlós
- Division of Gastroenterology, 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Mária Simon
- Department of Psychiatry and Psychotherapy, University of Pécs, Pécs, Hungary
| | - Katalin Márta
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Dániel Pécsi
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | | | - Judit Bajor
- Division of Gastroenterology, 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
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Fang H, King KS, Larson JJ, Snyder MR, Wu TT, Gandhi MJ, Murray JA. Undetectable negative tissue transglutaminase IgA antibodies predict mucosal healing in treated coeliac disease patients. Aliment Pharmacol Ther 2017; 46:681-687. [PMID: 28782118 DOI: 10.1111/apt.14250] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 05/30/2017] [Accepted: 07/12/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Tissue transglutaminase (tTG) immunoglobulin A (IgA) testing is a sensitive adjunct to the diagnosis of coeliac disease. The threshold for positivity was developed for diagnosis, with negative results reported as below the reference value (<4 U/mL). AIM To investigate if an undetectable (tTG IgA<1.2 U/mL) is more predictive of healing compared to patients with negative but detectable serology (1.2-3.9 U/mL). METHODS We performed a retrospective study of 402 treated coeliac disease patients seen at the Mayo Clinic with negative tTG IgA values drawn within 1 month of duodenal biopsy between January 2009 and December 2015. The Corazza-Villanacci score was used to assess mucosal healing. The presence of gastrointestinal symptoms was also collected. Logistic regression was used to assess the relationship of clinical variables with a normal biopsy. RESULTS Patients with undetectable titres more frequently had normal duodenal histology compared to patients with detectable tTG IgA levels (117/240 vs. 53/162; OR=1.96; 1.292, 2.961). Asymptomatic patients more frequently had normal duodenum as compared to symptomatic patients (88/163 vs. 82/239; OR=2.25; CI: 1.494, 3.377). Patients with undetectable serology and on a gluten-free diet for ≥2 years were more likely to have no villous atrophy compared to patients with detectable serology (148/192 vs. 55/88; OR=2.02; CI: 1.17, 3.49). CONCLUSION In subjects recovering from coeliac disease with negative tTG IgA serology, an undetectable titre is associated with normal histology on follow-up biopsy.
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Affiliation(s)
- H Fang
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - K S King
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - J J Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - M R Snyder
- Division of Clinical Biochemistry and Immunology, Mayo Clinic, Rochester, MN, USA
| | - T T Wu
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - M J Gandhi
- Division of Transfusion Medicine, Mayo Clinic, Rochester, MN, USA
| | - J A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Silvester JA, Kurada S, Szwajcer A, Kelly CP, Leffler DA, Duerksen DR. Tests for Serum Transglutaminase and Endomysial Antibodies Do Not Detect Most Patients With Celiac Disease and Persistent Villous Atrophy on Gluten-free Diets: a Meta-analysis. Gastroenterology 2017; 153:689-701.e1. [PMID: 28545781 PMCID: PMC5738024 DOI: 10.1053/j.gastro.2017.05.015] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 05/09/2017] [Accepted: 05/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Tests to measure serum endomysial antibodies (EMA) and antibodies to tissue transglutaminase (tTG) were developed to screen for celiac disease in patients consuming gluten. However, they are commonly used to monitor patients on a gluten-free diet (GFD). We conducted a meta-analysis to assess the sensitivity and specificity of tTG IgA and EMA IgA assays in identifying patients with celiac disease who have persistent villous atrophy despite a GFD. METHODS We searched PUBMED, EMBASE, BIOSIS, SCOPUS, clinicaltrials.gov, Science Citation Index, and Cochrane Library databases through November 2016. Inclusion criteria were studies of subjects with biopsy-confirmed celiac disease, follow-up biopsies, and measurement of serum antibodies on a GFD, biopsy performed on subjects regardless of symptoms, or antibody test results. Our analysis excluded subjects with refractory celiac disease, undergoing gluten challenge, or consuming a prescribed oats-containing GFD. Tests were considered to have positive or negative findings based on manufacturer cut-off values. Villous atrophy was defined as a Marsh 3 lesion or villous height:crypt depth ratio below 3.0. We constructed forest plots to determine the sensitivity and specificity of detection for individual studies. For the meta-analysis, a bivariate random effects model was used to jointly model sensitivity and specificity. RESULTS Our search identified 5408 unique citations. Following review of abstracts, 442 articles were reviewed in detail. Only 26 studies (6 of tTG assays, 15 of EMA assays, and 5 of tTG and EMA assays) met our inclusion criteria. The most common reason studies were excluded from our analysis was inability to cross-tabulate histologic and serologic findings. The serum assays identified patients with persistent villous atrophy with high levels of specificity: 0.83 for the tTG IgA assay (95% CI, 0.79-0.87) and 0.91 for the EMA IgA assay (95% CI, 0.87-0.94). However, they detected villous atrophy with low levels of sensitivity: 0.50 for the tTG IgA assay (95% CI, 0.41-0.60) and 0.45 for the EMA IgA assay (95% CI, 0.34-0.57). The tests had similar levels of performance in pediatric and adult patients. CONCLUSIONS In a meta-analysis of patients with biopsy-confirmed celiac disease undergoing follow-up biopsy on a GFD, we found that tests for serum tTG IgA and EMA IgA levels had low sensitivity (below 50%) in detection of persistent villous atrophy. We need more-accurate non-invasive markers of mucosal damage in children and adults with celiac disease who are following a GFD.
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Affiliation(s)
- Jocelyn A Silvester
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 3P5,Celiac Research Program, Harvard Medical School,Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115,Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
| | - Satya Kurada
- Celiac Research Program, Harvard Medical School,Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
| | - Andrea Szwajcer
- University of Manitoba Health Sciences Libraries, Winnipeg, MB, Canada
| | - Ciarán P Kelly
- Celiac Research Program, Harvard Medical School,Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
| | - Daniel A Leffler
- Celiac Research Program, Harvard Medical School,Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
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Abstract
OBJECTIVES Limited pediatric data exist examining the trend and predictors of antitissue transglutaminase (atTG) normalization over time in children with celiac disease (CD). We aimed to evaluate time to normalization of atTG in children after CD diagnosis, and to assess for independent predictors affecting this duration. METHODS A retrospective chart review was completed in pediatric patients with CD diagnosed from 2007 to 2014 at the Stollery Children's Hospital Celiac Clinic (Edmonton, Alberta, Canada). The clinical predictors assessed for impact on time to atTG normalization were initial atTG, Marsh score at diagnosis, gluten-free diet compliance (GFDC), age at diagnosis, sex, ethnicity, medical comorbidities, and family history of CD. Kaplan-Meier survival analysis was completed to assess time to atTG normalization, and Cox regression to assess for independent predictors of this time. RESULTS A total of 487 patients met inclusion criteria. Approximately 80.5% of patients normalized atTG levels. Median normalization time was 407 days for all patients (95% confidence interval [CI: 361-453]), and 364 days for gluten-free diet compliant patients (95% CI [335-393]). Type 1 diabetes mellitus (T1DM) patients took significantly longer to normalize at 1204 days (95% CI [199-2209], P < 0.001). Cox regression demonstrated T1DM (hazard ratio = 0.36 [0.24-0.55], P < 0.001) and higher baseline atTG (hazard ratio = 0.52 [0.43-0.63], P < 0.001) were significant predictors of longer atTG normalization time. GFDC was a significant predictor of earlier normalization (OR = 13.91 [7.86-24.62], P < 0.001). CONCLUSIONS GFDC and lower atTG at diagnosis are predictors of earlier normalization. Patients with T1DM are less likely to normalize atTG levels, with longer normalization time. Additional research and education for higher-risk populations are needed.
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Scherf KA, Ciccocioppo R, Pohanka M, Rimarova K, Opatrilova R, Rodrigo L, Kruzliak P. Biosensors for the Diagnosis of Celiac Disease: Current Status and Future Perspectives. Mol Biotechnol 2017; 58:381-92. [PMID: 27130174 DOI: 10.1007/s12033-016-9940-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Celiac disease (CD) is an autoimmune enteropathy initiated and sustained by the ingestion of gluten in genetically susceptible individuals. It is caused by a dysregulated immune response toward both dietary antigens, the gluten proteins of wheat, rye, and barley, and autoantigens, the enzyme tissue transglutaminase (TG2). The small intestine is the target organ. Although routine immunochemical protocols for a laboratory diagnosis of CD are available, faster, easier-to-use, and cheaper analytical devices for CD diagnosis are currently unavailable. This review focuses on biosensors, consisting of a physicochemical transducer and a bioreceptor, as promising analytical tools for diagnosis of CD and other diseases. Examples of recently developed biosensors as well as expectations for future lines of research and development in this field are presented.
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Affiliation(s)
| | - Rachele Ciccocioppo
- Clinica Medica I, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Miroslav Pohanka
- Faculty of Military Health Sciences, University of Defence, Hradec Kralove, Czech Republic
| | - Kvetoslava Rimarova
- Department of Public Health and Hygiene, Faculty of Medicine, Pavol Jozef Safarik University, Kosice, Slovakia
| | - Radka Opatrilova
- Department of Chemical Drugs, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Brno, Czech Republic
| | - Luis Rodrigo
- Department of Gastroenterology, Central University Hospital of Asturias (HUCA), Oviedo, Spain
| | - Peter Kruzliak
- Laboratory of Structural Biology and Proteomics, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackeho tr 1946/1, 612 42, Brno, Czech Republic.
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Abstract
Prevalence studies from around the world have established a substantial increase in the prevalence of celiac disease (CD) in patients with type 1 diabetes mellitus (T1DM). Approximately two-thirds of patients with T1DM and CD are asymptomatic for CD at diagnosis. We aim to provide an up-to-date state-of-the-art summary of the recommendations for serologic testing for CD in patients with T1DM and to clarify the debate on the need for screening and interventions. We searched Medline and Cochrane databases for studies of celiac autoimmunity and biopsy-proven CD in people with T1DM between January 1, 2000 and December 1, 2015. CD was found to be an independent risk factor for micro- and macrovascular complications, as well as for increased morbidity in patients with T1DM. Publications, however, reveal controversy regarding the benefits of a gluten-free diet (GFD) on glycemic control, bone health, and quality of life in individuals with T1DM and asymptomatic CD. A multicenter, prospective randomized controlled trial aimed to investigate this issue is currently ongoing. Until resolution of the pros and cons of screening for CD, and of the benefit versus burden of GFD treatment in T1DM patients with asymptomatic CD, we recommend repeated screening for CD during childhood and adulthood, and treatment with GFD for those with biopsy-proven CD, even if asymptomatic.
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Affiliation(s)
- Batia Weiss
- *Pediatric Gastroenterology Unit †Pediatric Endocrine & Diabetes Unit, Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan ‡Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Isreal
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Ganji A, Esmaeilzadeh A, Bahari A, Ghafarzadegan K, Afzal Aghayee M, Mosanen Mozafari H, Hayatbakhsh A, Ghavami Ghanbarabadi V, Ravarian B, Rahimi L. Correlation Between Cut-off Level of Tissue Transglutaminase Antibody and Marsh Classification. Middle East J Dig Dis 2016; 8:318-322. [PMID: 27957296 PMCID: PMC5145300 DOI: 10.15171/mejdd.2016.42] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Duodenal biopsy is required for diagnosis of celiac disease in adults, although some studies have suggested adequate accuracy of serology alone. Objective: We aimed to assess the correlation between anti-tissue transglutaminase (tTG) titer and pathological findings and to define the specific level of tTG for predicting celiac disease in adults without the need for biopsy sampling. METHODS This descriptive study was done on 299 participants. The tTG titer and pathological findings of duodenal biopsy samples were used for this study. Analysis of Receiver operating characteristic (ROC) curve was used to find a cut-off point of anti-tTG antibody for mucosal atrophy. RESULTS Mean tTG titers was significantly higher in patients graded as Marsh III≥ 3 (p=0.023). ROC curve analysis showed 89.1% sensitivity for cut-off point≥76.5 IU/mL of anti-tTG. For Marsh≥ II, specificity was 28% and positive predictive value was 91%.CON CLUSION There is a linear correlation between increasing tTG level and Marsh I to III. Specificity of tTG titer more than 200 was 100% for Marsh >2.
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Affiliation(s)
- Azita Ganji
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abbas Esmaeilzadeh
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Bahari
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mehdi Afzal Aghayee
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Homan Mosanen Mozafari
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abdolrasol Hayatbakhsh
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vahid Ghavami Ghanbarabadi
- PHD candidate in Biostatistics, Department of Epidemiology and Biostatistics, School of Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Behdad Ravarian
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leili Rahimi
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Calderoni S, Santocchi E, Del Bianco T, Brunori E, Caponi L, Paolicchi A, Fulceri F, Prosperi M, Narzisi A, Cosenza A, Tancredi R, Muratori F. Serological screening for Celiac Disease in 382 pre-schoolers with Autism Spectrum Disorder. Ital J Pediatr 2016; 42:98. [PMID: 27852289 PMCID: PMC5112719 DOI: 10.1186/s13052-016-0308-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 11/12/2016] [Indexed: 01/01/2023] Open
Abstract
Background Recent investigations suggest a possible common genetic background between Autism Spectrum Disorders (ASD) and Celiac Disease (CD). However, studies regarding this association are scarce and often limited by the small sample sizes and/or large heterogeneity among ASD groups in terms of demographic and clinical features. The present study aims to investigate the overall CD prevalence (biopsy proven-CD patients plus screening detected tTG and EMA positive cases) in a large population of pre-schoolers with ASD referred to a tertiary care University Hospital. Methods We retrospectively collected data about 382 children (mean age: 46.97 ± 13.55 months; age-range: 18-72 months) consecutively diagnosed as ASD (according to the Diagnostic and Statistical Manual of Mental Disorders 4th edition criteria) over the period 2010–2013, and who performed a serological CD screening. Results The overall CD prevalence was 2.62%, which is statistically significant higher to that reported in the Italian paediatric population (p = 0.0246). Half of these children had no symptoms or risk factors related to CD when they performed the serological screening. Conclusions If replicated, these data suggest the importance of regular screening for CD in young patients with ASD, and are of relevance for clinical and public health.
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Affiliation(s)
- Sara Calderoni
- IRCCS Stella Maris Foundation, Viale del Tirreno 331, Pisa, 56018, Calambrone, Italy. .,Stella Maris Mediterraneo Foundation, Chiaromonte, (PZ), Italy.
| | - Elisa Santocchi
- IRCCS Stella Maris Foundation, Viale del Tirreno 331, Pisa, 56018, Calambrone, Italy
| | - Teresa Del Bianco
- ODFlab, Department of Psychology and Cognitive Science, University of Trento, Via Matteo del Ben, 5/B, 38068, Rovereto (TN), Italy
| | - Elena Brunori
- IRCCS Stella Maris Foundation, Viale del Tirreno 331, Pisa, 56018, Calambrone, Italy
| | - Laura Caponi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Aldo Paolicchi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Francesca Fulceri
- IRCCS Stella Maris Foundation, Viale del Tirreno 331, Pisa, 56018, Calambrone, Italy
| | - Margherita Prosperi
- IRCCS Stella Maris Foundation, Viale del Tirreno 331, Pisa, 56018, Calambrone, Italy
| | - Antonio Narzisi
- IRCCS Stella Maris Foundation, Viale del Tirreno 331, Pisa, 56018, Calambrone, Italy.,Stella Maris Mediterraneo Foundation, Chiaromonte, (PZ), Italy
| | - Angela Cosenza
- IRCCS Stella Maris Foundation, Viale del Tirreno 331, Pisa, 56018, Calambrone, Italy
| | - Raffaella Tancredi
- IRCCS Stella Maris Foundation, Viale del Tirreno 331, Pisa, 56018, Calambrone, Italy
| | - Filippo Muratori
- IRCCS Stella Maris Foundation, Viale del Tirreno 331, Pisa, 56018, Calambrone, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Fecal Gluten Peptides Reveal Limitations of Serological Tests and Food Questionnaires for Monitoring Gluten-Free Diet in Celiac Disease Patients. Am J Gastroenterol 2016; 111:1456-1465. [PMID: 27644734 PMCID: PMC5059698 DOI: 10.1038/ajg.2016.439] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/24/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Treatment for celiac disease (CD) is a lifelong strict gluten-free diet (GFD). Patients should be followed-up with dietary interviews and serology as CD markers to ensure adherence to the diet. However, none of these methods offer an accurate measure of dietary compliance. Our aim was to evaluate the measurement of gluten immunogenic peptides (GIP) in stools as a marker of GFD adherence in CD patients and compare it with traditional methods of GFD monitoring. METHODS We performed a prospective, nonrandomized, multicenter study including 188 CD patients on GFD and 84 healthy controls. Subjects were given a dietary questionnaire and fecal GIP quantified by enzyme-linked immunosorbent assay (ELISA). Serological anti-tissue transglutaminase (anti-tTG) IgA and anti-deamidated gliadin peptide (anti-DGP) IgA antibodies were measured simultaneously. RESULTS Of the 188 celiac patients, 56 (29.8%) had detectable GIP levels in stools. There was significant association between age and GIP in stools that revealed increasing dietary transgressions with advancing age (39.2% in subjects ≥13 years old) and with gender in certain age groups (60% in men ≥13 years old). No association was found between fecal GIP and dietary questionnaire or anti-tTG antibodies. However, association was detected between GIP and anti-DGP antibodies, although 46 of the 53 GIP stool-positive patients were negative for anti-DGP. CONCLUSIONS Detection of gluten peptides in stools reveals limitations of traditional methods for monitoring GFD in celiac patients. The GIP ELISA enables direct and quantitative assessment of gluten exposure early after ingestion and could aid in the diagnosis and clinical management of nonresponsive CD and refractory CD. Trial registration number NCT02711397.
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Lindo Ricce M, Rodriguez-Batllori Arán B, Jiménez Gómez M, P Gisbert J, Santander C. Non-responsive coeliac disease: Coeliac crisis vs. refractory coeliac disease with response to corticosteroids. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 40:529-530. [PMID: 27544909 DOI: 10.1016/j.gastrohep.2016.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/10/2016] [Accepted: 07/08/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Mayra Lindo Ricce
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, España.
| | - Beatriz Rodriguez-Batllori Arán
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, España
| | - Mirella Jiménez Gómez
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, España
| | - Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, España
| | - Cecilio Santander
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, España
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Abstract
Dietary exclusion of gluten-containing products has become increasingly popular in the general population, and currently ∼30% of people in the United States are limiting gluten ingestion. Although celiac disease (CD), wheat allergy (WA), and nonceliac gluten sensitivity (NCGS) constitute a spectrum of gluten-related disorders that require exclusion of gluten from the diet, together these account for a relatively small percentage of those following a gluten-free diet, and the vast majority has no medical necessity for doing so. Differentiating between CD, WA, and NCGS has important prognostic and therapeutic implications. Because of the protean manifestations of gluten-related disorders, it is not possible to differentiate between them on clinical grounds alone. This clinical report will compare and contrast the manifestations of gluten-related disorders, emphasize the importance of differentiating between these conditions, discuss initial and subsequent tests needed to confirm the diagnosis, and provide recommendations on treatment and follow-up for each condition.
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Austin AS, Forsyth JM, Hill PG, Holmes GKT. Authors' response: British Society of Gastroenterology guidelines on the diagnosis and management of coeliac disease. Gut 2016; 65:717. [PMID: 26268742 DOI: 10.1136/gutjnl-2015-310202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 07/23/2015] [Indexed: 12/28/2022]
Affiliation(s)
- Andrew S Austin
- Derby Digestive Diseases Centre, Royal Derby Hospital, Derby, UK
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de Chaisemartin L, Meatchi T, Malamut G, Fernani-Oukil F, Hosking F, Rault D, Bellery F, Cellier C, Dragon-Durey MA. Application of Deamidated Gliadin Antibodies in the Follow-Up of Treated Celiac Disease. PLoS One 2015; 10:e0136745. [PMID: 26322980 PMCID: PMC4554732 DOI: 10.1371/journal.pone.0136745] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 08/06/2015] [Indexed: 12/31/2022] Open
Abstract
Introduction The role of serological tests such as IgA anti-transglutaminase autoantibodies has become increasingly important in celiac disease (CD) diagnosis. However, the efficiency of these tests for patient follow-up is controversial. We investigated the correlation of 12 different serological tests, including recent deamidated gliadin and actin IgA tests, with villous atrophy (VA) in a retrospective cohort of treated celiac patients. Materials and Methods Serum samples were collected from 100 treated CD patients who had intestinal biopsy in the course of their follow-up. Antibodies against transglutaminase, deamidated gliadin peptides, and native gliadin were measured, along with IgA anti-actin. The biopsy slides were all blind-reviewed and scored according to Marsh classification. Results For all deamidated gliadin and transglutaminase tests, we found that a positive result was significantly associated with persistence of intestinal VA, with a diagnostic efficacy up to 80%. Furthermore, antibodies titers directly correlated with the degree of VA, indicating a strong link between disease activity and presence of antibodies in the serum. Interestingly, the tests with the highest association with persistent VA were those for deamidated gliadin IgG. Using a test positivity pattern analysis, we were also able to identify several groups of patients with distinct antibody profiles that showed significant differences in intestinal damage and diet compliance. Conclusions Altogether, these results show that deamidated gliadin antibodies are strongly correlated with VA and should be considered valuable tools in CD follow-up and that multiplex serologic analysis for treated CD represents a promising tool for personalized patient management.
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Affiliation(s)
- Luc de Chaisemartin
- Immunology Department, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM UMR 996, Paris Sud University, Châtenay-Malabry, France
| | - Tchao Meatchi
- Pathology Department, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Georgia Malamut
- Gastroenterology Department, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Descartes University, Paris, France
| | - Fahima Fernani-Oukil
- Immunology Department, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Frédérique Hosking
- Immunology Department, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Dorothée Rault
- Gastroenterology Department, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Fabienne Bellery
- Immunology Department, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christophe Cellier
- Gastroenterology Department, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Descartes University, Paris, France
| | - Marie-Agnès Dragon-Durey
- Immunology Department, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Descartes University, Paris, France
- * E-mail:
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Aziz I, Key T, Goodwin JG, Sanders DS. Predictors for Celiac Disease in Adult Cases of Duodenal Intraepithelial Lymphocytosis. J Clin Gastroenterol 2015; 49:477-82. [PMID: 25014240 DOI: 10.1097/mcg.0000000000000184] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Duodenal intraepithelial lymphocytosis (D-IEL) is an early marker for celiac disease (CD). However, the majority of cases are due to non-CD-related conditions. GOALS To identify the predictors of CD when presented with D-IEL. METHODS A total of 215 adult patients with D-IEL had undergone prospective and systematic evaluation for CD and other recognized associations.The gold-standard diagnosis of CD was based upon the presence of HLA-DQ2 and/or DQ8, persistence or progression of D-IEL following a gluten challenge, followed by symptomatic improvement on a gluten-free diet.Binary logistic regression models, adjusting for age and sex, were subsequently performed to compare presenting variables between CD and non-CD cases, and to determine their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS CD was diagnosed in 48 cases (22%) and non-CD in 167 cases (78%). There was no statistical difference in baseline demographics, clinical symptoms (ie, diarrhea, weight loss, abdominal pain), anemia, or hematinics between the CD and non-CD group.Patients with CD, in comparison with non-CD, were significantly more likely to have a positive family history of CD (21% vs. 3.6%, OR 6.73; PPV 62.5%, NPV 81%, specificity 96.4%), positive HLA-DQ status (100% vs. 49.1%; PPV 36.4%, NPV 100%, specificity 50.9%), and presence of endomysial antibody (EMA) (48% vs. 0%; PPV 100%, NPV 87%, specificity 100%); all P≤0.001.A normal tissue transglutaminase antibody (TTG) level was seen in 29.2% CD and 83.2% non-CD cases (OR 0.084, P<0.001; PPV 9.2%). There was no difference in the prevalence of TTG levels 1 to 2×upper limit of normal (ULN) between the groups (29.2% CD vs. 14.4% non-CD; PPV 33% to 38%). However, TTG levels between 3 and 20×ULN were significantly more prevalent in the CD group (33.3% vs. 2.4%, PPV 66.6% to 89%), whereas a TTG>20×ULN was exclusive to CD (8.3%, P<0.001, PPV 100%). CONCLUSIONS In the setting of D-IEL, only the presence of a positive EMA or TTG>20×ULN at the outset can be used to make an immediate diagnosis of CD. Gastrointestinal symptoms, family history, anemia, or other celiac serology results do not reliably distinguish CD from non-CD without further investigations.
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Affiliation(s)
- Imran Aziz
- *Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals †Department of Histocompatability & Immunogenetics, NHS Blood & Transplant Centre, Sheffield, UK
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Celiac disease can be predicted by high levels of anti-tissue transglutaminase antibodies in population-based screening. J Pediatr Gastroenterol Nutr 2015; 60:787-91. [PMID: 25564816 DOI: 10.1097/mpg.0000000000000688] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of the present study was to evaluate any potential correlation between anti-tissue transglutaminase antibodies of type immunoglobulin A (tTG-IgA) and the degree of gluten-induced enteropathy in children participating in a screening study for celiac disease (CD) and to assess to what extent the revised European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) guidelines cover this group of patients. METHODS The present study is a substudy of a cross-sectional CD screening study, Exploring the Iceberg of Celiacs in Sweden, a 2-phased study performed during 2005 to 2006 and 2009 to 2010. The 13,279 participating children had a blood test obtained, and those with positive tTG-IgA were recommended a small intestinal biopsy. The tTG-IgA levels at the time of biopsy were compared with those at the assessment of the biopsy. RESULTS There were 267 children included, of whom 230 were diagnosed as having CD. Of all of the children, 67 children had low tTG-IgA levels (<5 U/mL), of whom 55% had Marsh 3 lesions. All of the children with tTG-IgA levels exceeding 10 times the upper limit of normal values of 5 U/mL, that is, 50 U/mL, were diagnosed as having CD. Lowering the cutoff to 3 U/mL, all but 1 child with 30 U/mL got CD diagnosis. CONCLUSIONS By adopting the revised ESPGHAN criteria, biopsies could have been omitted in one-fourth of all of the patients. Our results indicate that the criteria may be useful even in screened children. Further studies are needed to confirm whether the 2012 ESPGHAN guidelines should be revised to also apply to the populations being screened.
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