Latest developments in the pathogenesis and treatment of celiac disease

The Role of the Gallbladder, the Intestinal Barrier and the Gut Microbiota in the Development of Food Allergies and Other Disorders

The microbiota present in the gastrointestinal tract is involved in the development or prevention of food allergies and autoimmune disorders; these bacteria can enter the gallbladder and, depending on the species involved, can either be benign or cause significant diseases. Occlusion of the gallbladder, usually due to the presence of calculi blocking the bile duct, facilitates microbial infection and inflammation, which can be serious enough to require life-saving surgery. In addition, the biliary salts are secreted into the intestine and can affect the gut microbiota. The interaction between the gut microbiota, pathogenic organisms, and the human immune system can create intestinal dysbiosis, generating a variety of syndromes including the development of food allergies and autoimmune disorders. The intestinal microbiota can aggravate certain food allergies, which become severe when the integrity of the intestinal barrier is affected, allowing bacteria, or their metabolites, to cross the intestinal barrier and invade the bloodstream, affecting distal body organs. This article deals with health conditions and severe diseases that are either influenced by the gut flora or caused by gallbladder obstruction and inflammation, as well as putative treatments for those illnesses.

Leaky Gut and Autoimmunity: An Intricate Balance in Individuals Health and the Diseased State

Damage to the tissue and the ruining of functions characterize autoimmune syndromes. This review centers around leaky gut syndromes and how they stimulate autoimmune pathogenesis. Lymphoid tissue commonly associated with the gut, together with the neuroendocrine network, collaborates with the intestinal epithelial wall, with its paracellular tight junctions, to maintain the balance, tolerance, and resistance to foreign/neo-antigens. The physiological regulator of paracellular tight junctions plays a vital role in transferring macromolecules across the intestinal barrier and thereby maintains immune response equilibrium. A new paradigm has explained the intricacies of disease development and proposed that the processes can be prevented if the interaction between the genetic factor and environmental causes is barred by re-instituting the intestinal wall function. The latest clinical evidence and animal models reinforce this current thought and offer the basis for innovative methodologies to thwart and treat autoimmune syndromes.

Formulation and biochemical evaluation of designer diet enriched with botanicals for bone health

The study designed to evaluate the role of sesame, fenugreek flax, and nuts seeds as best alternatives for therapeutic agents to improve bone mineral status. Effect of these plant seeds on proximate composition, antioxidant potential, mineral, fatty acid, and amino acid profile of supplements was studied. The sesame, fenugreek, and flaxseeds were incorporated with nuts at level of 35% to develop supplement. Improved contents of protein, fat, and NFE were recorded in range of 25.72-32.23, 18.92-23.15, and 34.25%-39.59%, correspondingly. The antioxidant potential of supplements is high (450.56 mg GAE/ 100g) prepared with fenugreek followed by flaxseeds and sesame seeds. Calcium as fundamental bone mineral found greater (525.15%-790.21%) in seed-based supplement. Enhanced contents of Oleic, linoleic, and linolenic acids ranged 17.32-41.78, 21.72-44.23, and 1.00%-47.12%, respectively. Nutritional enriched supplements may be best alternatives for improving bone health by lowering osteoclast and increasing osteoblast mechanism in bone development.

Physician Review of a Celiac Disease Risk Estimation and Decision-Making Expert System

Objective: Celiac disease is a genetic disease affecting people of all ages, resulting in small intestine enteropathy. It is considered to be a clinical chameleon. Average prevalence of celiac disease is 1 out of 100 people with data indicating the risk may be as high as 22% for those with first-degree relatives with the disease. Eighty-three percent of people with celiac disease may be undiagnosed. Average duration to diagnosis is 10 years. Data indicate that there is a lack of consensus regarding diagnostics and symptomatology.Method: A clinical decision support system (CDSS) was developed using Exsys Corvid for expert analysis (CD-CDSS). The CD-CDSS was divided into symptoms and manifestations with 80 points of navigation, and a serology section, and was validated by 13 experts in the field of celiac disease using a 10-statement 5-point Likert scale.Results: This scale was analyzed using Cronbach's alpha reliability coefficient, which was calculated using SPSS and revealed good internal consistency and reliability with a result of 0.813. One hundred percent of experts agreed that the CD-CDSS is capable of guiding a health care professional through the diagnostic process, contains an accurate list of symptoms based on the clinical literature, and can foster improved awareness and education about celiac disease and that there is a need for this system.Conclusions: A celiac disease risk estimation and decision-making expert system was successfully developed and evaluated by medical professionals, with 100% agreeing that this CD-CDSS is medically accurate and can guide health care professionals through the diagnostic process.

Clinical intervention using Bifidobacterium strains in celiac disease children reveals novel microbial modulators of TNF-α and short-chain fatty acids

BACKGROUND & AIMS

Celiac disease (CD) is an immune-mediated systemic disease, caused by ingestion of gluten in genetically predisposed individuals. Gut microbiota dysbiosis might play a significant role in pathogenesis of chronic enteropathies and its modulation can be used as an intervention strategy in CD as well. In this study, we aimed to identify correlations between fecal microbiota, serum tumor necrosis factor alpha (TNF-α) and fecal short-chain fatty acids (SCFAs) in healthy children and children with CD after administration of probiotic Bifidobacterium breve BR03 and B632.

METHODS

A double-blind placebo-controlled study enrolled 40 children with CD (CD) and 16 healthy children (HC). CD children were randomly allocated into two groups, of which 20 belonged to the placebo (PL) group and 20 to the Probiotic (PR) group. The PR group received a probiotic formulation containing a mixture of 2 strains, B. breve BR03 (DSM 16604) and B. breve B632 (DSM 24706) in 1:1 ratio for 3 months. Subsequently, for statistical analysis, blood and fecal samples from CD children (on enrolment - T0 and after 3 months, at the end of intervention with probiotic/placebo - T1) and HC children were used. The HC group was sampled only once (T0).

RESULTS

Verrucomicrobia, Parcubacteria and some yet unknown phyla of Bacteria and Archaea may be involved in the disease, indicated by a strong correlation to TNF-α. Likewise, Proteobacteria strongly correlated with fecal SCFAs concentration. The effect of probiotic administration has disclosed a negative correlation between Verrucomicrobia, some unknown phyla of Bacteria, Synergistetes, Euryarchaeota and some SCFAs, turning them into an important target in microbiome restoration process. Synergistetes and Euryarchaeota may have a role in the anti-inflammatory process in healthy human gut.

CONCLUSIONS

Our results highlight new phyla, which may have an important relation to disease-related parameters, CD itself and health.

T Helper Lymphocyte and Mast Cell Immunohistochemical Pattern in Nonceliac Gluten Sensitivity

Background and Aims

Nonceliac gluten sensitivity (NCGS) is a gluten-related emerging condition. Since few data about NCGS histopathology is available, we assessed the markers of lymphocyte and innate immunity activation.

Materials and Methods

We retrieved duodenal biopsy samples of patients with NCGS diagnosis according to the Salerno criteria. We selected specimens of positive (seropositive celiac disease/Marsh 1-2 stage) and negative (normal microscopic picture) controls. Immunohistochemistry for CD3 (intraepithelial lymphocytes-IELs), CD4 (T helper lymphocytes), CD8 (T cytotoxic lymphocytes), and CD1a/CD117 (Langerhans/mast cells) was performed. ANOVA plus Bonferroni's tests were used for statistical analysis.

Results

Twenty NCGS, 16 celiac disease, and 16 negative controls were selected. CD3 in NCGS were higher than negative controls and lower than celiac disease (18.5 ± 6.4, 11.9 ± 2.8, and 40.8 ± 8.1 IELs/100 enterocytes; p < 0.001). CD4 were lower in NCGS than controls and celiac disease (31.0 ± 22.1, 72.5 ± 29.5, and 103.7 ± 15.7 cells/mm²; p < 0.001). CD8 in NCGS were similar to negative controls, but lower than celiac disease (14.0 ± 7.4 and 34.0 ± 7.1 IELs/100 enterocytes, p < 0.001). CD117 were higher in NCGS than celiac disease and negative controls (145.8 ± 49.9, 121.3 ± 13.1, and 113.5 ± 23.4 cells/mm²; p = 0.009).

Conclusions

The combination of CD4 and CD117, as well as IEL characterization, may be useful to support a clinical diagnosis of NCGS.

Celiac Disease and Nonceliac Gluten Sensitivity

Gluten-related disorders include celiac disease (CD), wheat allergy, and nonceliac gluten sensitivity. CD is an autoimmune enteropathy caused by damage to small intestinal mucosa when gluten is ingested in genetically susceptible individuals. Currently, the only available treatment of CD is gluten-free diet. Several potential treatments are being researched. Wheat allergy is a hypersensitivity reaction caused by IgE-mediated and/or non-IgE-mediated immune response, and can involve the gastrointestinal tract, skin, or respiratory tract. Nonceliac gluten sensitivity is one of a variety of immunologic, morphologic, or symptomatic manifestations precipitated by ingestion of gluten in individuals in whom CD and wheat allergy are excluded.

Administration of Bifidobacterium breve Decreases the Production of TNF-α in Children with Celiac Disease

BACKGROUND

Increasing evidence suggests that not only genetics, but also environmental factors like gut microbiota dysbiosis play an important role in the pathogenesis of celiac disease (CD).

AIM

The aim of our study was to investigate the effect of two probiotic strains Bifidobacterium breve BR03 and B. breve B632 on serum production of anti-inflammatory cytokine interleukin 10 (IL-10) and pro-inflammatory cytokine tumor necrosis factor alpha (TNF-α) in children with CD.

METHODS

The study was a double-blinded, placebo-controlled trial that included 49 children with CD on gluten-free diet (GFD) randomized into two groups and 18 healthy children in the control group. The first group (24 children with CD) daily received B. breve BR03 and B632 (2 × 10(9) colony-forming units) and the second group (25 children with CD) received placebo for 3 months.

RESULTS

TNF-α levels were significantly decreased in the first group after receiving B. breve for 3 months. On follow-up, 3 months after receiving probiotics, TNF-α levels increased again. Children with CD who were on GFD for less than 1 year showed similar baseline TNF-α levels as children who were on GFD for more than 1 year. IL-10 levels were in all groups of patients below detection level.

CONCLUSIONS

Probiotic intervention with B. breve strains has shown a positive effect on decreasing the production of pro-inflammatory cytokine TNF-α in children with CD on GFD.

Leaky gut and autoimmune diseases

Autoimmune diseases are characterized by tissue damage and loss of function due to an immune response that is directed against specific organs. This review is focused on the role of impaired intestinal barrier function on autoimmune pathogenesis. Together with the gut-associated lymphoid tissue and the neuroendocrine network, the intestinal epithelial barrier, with its intercellular tight junctions, controls the equilibrium between tolerance and immunity to non-self antigens. Zonulin is the only physiologic modulator of intercellular tight junctions described so far that is involved in trafficking of macromolecules and, therefore, in tolerance/immune response balance. When the zonulin pathway is deregulated in genetically susceptible individuals, autoimmune disorders can occur. This new paradigm subverts traditional theories underlying the development of these diseases and suggests that these processes can be arrested if the interplay between genes and environmental triggers is prevented by re-establishing the zonulin-dependent intestinal barrier function. Both animal models and recent clinical evidence support this new paradigm and provide the rationale for innovative approaches to prevent and treat autoimmune diseases.

Zonulin, regulation of tight junctions, and autoimmune diseases

Recent studies indicate that besides digestion and absorption of nutrients and water and electrolytes homeostasis, another key function of the intestine is to regulate the trafficking of environmental antigens across the host mucosal barrier. Intestinal tight junctions (TJs) create gradients for the optimal absorption and transport of nutrients and control the balance between tolerance and immunity to nonself antigens. To meet diverse physiological challenges, intestinal epithelial TJs must be modified rapidly and in a coordinated fashion by regulatory systems that orchestrate the state of assembly of the TJ multiprotein network. While considerable knowledge exists about TJ ultrastructure, relatively little is known about their physiological and pathophysiological regulation. Our discovery of zonulin, the only known physiologic modulator of intercellular TJs described so far, has increased our understanding of the intricate mechanisms that regulate the intestinal epithelial paracellular pathway and has led us to appreciate that its upregulation in genetically susceptible individuals leads to autoimmune diseases.

Influence of breastfeeding versus formula feeding on lymphocyte subsets in infants at risk of coeliac disease: the PROFICEL study

PURPOSE

In addition to genetic risk, environmental factors might influence coeliac disease (CD) development. We sought to assess the effect of the interaction between milk-feeding practices and the HLA-DQ genotype on peripheral lymphocyte subsets and their activation markers in infants at familial risk for CD.

METHODS

170 newborns were classified in 3 different genetic risk groups (high risk, HR; intermediate risk, IR; and low risk, LR) after DQB1 and DQA1 typing. Lymphocyte subsets were studied at the age of 4 months by flow cytometry analysis.

RESULTS

79 infants were receiving exclusive breastfeeding (BF) and 91 partial breastfeeding or formula feeding (FF). Regarding genetic risk, 40 infants were classified in HR group, 75 in IR group and 55 in LR group. Two-way ANOVA did not show significant interactions between the type of milk feeding and genetic risk group on the lymphocyte subsets analysed. One-way ANOVA for milk-feeding practice alone showed that the percentage of CD4 + CD25+ cells was significantly higher in BF group than in FF group (BF, 10.92 ± 2.71; FF, 9.94 ± 2.96; p = 0.026), and absolute counts of CD4 + CD38+ cells were significantly higher in FF group than in BF group (FF, 2,881.23 ± 973.48; BF, 2,557.95 ± 977.06; p = 0.038). One-way ANOVA for genetic risk alone showed that absolute counts of NK cells were significantly higher in IR group than HR and LR groups (IR, 539.24 ± 340.63; HR, 405.01 ± 239.53; LR, 419.86 ± 262.85; p = 0.028).

CONCLUSION

Lymphocyte subset profiles in the early stages of life could be modulated by milk-feeding practices and genetic risk separately. Breastfeeding might have a positive immunomodulatory effect on lymphocyte subsets in infants at risk of CD.

Prevalence of celiac disease in siblings of Iranian patients with celiac disease

CONTEXT

Celiac disease, one of the best-known autoimmune human leukocyte antigen-dependent disorders, has a relatively increased prevalence in first-degree relatives.

OBJECTIVE

To determine the prevalence of celiac disease in siblings of patients with confirmed celiac disease.

METHODS

Siblings of confirmed celiac disease patients in our center were identified and enrolled in this study. Their serum immunoglobulin A and tissue transglutaminase antibody-enzyme-linked immunosorbent assay (anti-tissue transglutaminase, immunoglobulin A, and immunoglobulin G) were measured and multiple endoscopic duodenal biopsy specimens were obtained with parental consensus. Celiac disease was confirmed by observation of characteristic histological changes.

RESULTS

A total of 49 children (male, 29; female, 20; age, 2-16 years) with confirmed celiac disease in a pediatric gastroenterology ward were studied from 1999 to 2006. We found 30 siblings (female, 16) all shared in both parents. The only measurement available was for immunoglobulin A tissue transglutaminase antibody. A duodenal biopsy was performed in all 30 siblings. Clinical findings such as abdominal pain, fatigue, growth retardation and diarrhea were found in 53.3% of the completely studied siblings, and positive serology without histological changes was identified in four cases. Both serology and biopsy (confirmed new cases) were positive in 2 of the 30 siblings.

CONCLUSION

High prevalence of celiac disease among siblings of patients with confirmed celiac disease necessitates serologic screening (and confirmatory biopsy if indicated) in families having celiac disease. It is advantageous to diagnose the disease as soon as possible because early diagnosis and diet intervention may prevent serious complications such as growth retardation, short stature, chronic diarrhea, and malignancy.

New insights in celiac disease

Celiac disease (CD) is an autoimmune disorder occurring in genetically susceptible subjects. The incidence of CD is around 1%, and it is much more common in first-degree relatives of CD patients, 10%-18%. However, the pattern of the genetic inheritance is still obscure. Environmental factors are undoubtedly affecting the disease's clinical presentation, time at presentation, and may have an effect on the characteristics of the disease. The clinical presentation of CD has shifted during the previous decades from the classical presentation in which the toddler suffers from diarrhea, constipation, vomiting, failure to thrive, abdominal distension, etc., to the child with a monosymptomatic presentation, such as anemia, as well as an enlarged list of extra-intestinal disorders. The diagnosis of CD is being established by symptoms consistent with CD and positive serology. The ultimate diagnosis should be made upon histological evaluation of the small bowel mucosa. The treatment of CD is a lifelong, strict gluten-free diet (GFD). Compliance with a GFD is quite difficult. Therefore, new strategies for prevention and treatment modalities other than GFD are greatly needed. Recently several promising therapeutic modalities have been developed; these include resuming traditional baking techniques. Another methodology is using probiotic-driven prolylendopeptidase. Another pathway to tackle the therapeutic option in CD is by down-regulation of the activity of zonulin-the active pump enabling gluten to enter the enterocytes. We are facing an era where other modalities beyond a GFD might allow CD patients to be able to tolerate occasionally a small amount of gluten in their diet.

Pharmacotherapy and management strategies for coeliac disease

INTRODUCTION

Coeliac disease is a common disease that affects approximately 1% of Northern European and American populations. Evidence suggests it is caused by an inappropriate immune response in genetically susceptible patients to dietary gluten found in wheat, rye, barley and, in a small minority of patients, oats. Treatment involves a lifelong gluten-free diet. This diet limits nutritional variety and is costly and difficult to maintain.

AREAS COVERED

This review covers the current treatment options available and discusses novel emerging therapies for coeliac disease.

EXPERT OPINION

Novel therapies are still in early stages of development and therefore, at present, a gluten-free diet remains the treatment of choice in coeliac disease due to its low side-effect profile. A replacement for a gluten-free diet would be superior to an adjunct; in this case dietary modification of gluten may well have the least side effects, be tolerated by a wider group of coeliac patients and therefore be accepted. Search terms used: Pubmed, Medline and clinicaltrials.gov were searched with 'celiac disease' and 'therapy' as MESH terms. Patent database was searched using the term 'celiac disease'. Conference attendance at DDW Chicago 2011 and Columbia 2010 was also used to gain further information from conference abstracts.

Pachyrhizus ahipa (Wedd.) Parodi roots and flour: Biochemical and functional characteristics

Ahipa roots' chemical composition and physiological parameters were characterised; ahipa flour preparation procedures were selected and the chemical composition and functional properties of these products were studied. Ahipa roots and flour can be considered alternative food sources of gluten-free starch, with a considerable contribution of protein, fibre and minerals, such as potassium, calcium and iron. The grating process for ahipa flour production required a pressing step (AFGP) and the recovery of the starch leached. The slicing procedure (AFS) was simpler and the resulting product showed higher contents of potassium, magnesium, calcium and protein than did AFGP, which showed lower sodium and higher acid detergent fibre contents, together with lower gelatinisation temperature. Both flours differed in terms of α-amylase activity and swelling power, characteristics that may condition their specific applications, such as the incorporation of these flours as gluten-free functional food ingredients.

Influence of environmental and genetic factors linked to celiac disease risk on infant gut colonization by Bacteroides species

Celiac disease (CD) is an immune-mediated enteropathy involving genetic and environmental factors whose interaction might influence disease risk. The aim of this study was to determine the effects of milk-feeding practices and the HLA-DQ genotype on intestinal colonization of Bacteroides species in infants at risk of CD development. This study included 75 full-term newborns with at least one first-degree relative suffering from CD. Infants were classified according to milk-feeding practice (breast-feeding or formula feeding) and HLA-DQ genotype (high or low genetic risk). Stools were analyzed at 7 days, 1 month, and 4 months by PCR and denaturing gradient gel electrophoresis (DGGE). The Bacteroides species diversity index was higher in formula-fed infants than in breast-fed infants. Breast-fed infants showed a higher prevalence of Bacteroides uniformis at 1 and 4 months of age, while formula-fed infants had a higher prevalence of B. intestinalis at all sampling times, of B. caccae at 7 days and 4 months, and of B. plebeius at 4 months. Infants with high genetic risk showed a higher prevalence of B. vulgatus, while those with low genetic risk showed a higher prevalence of B. ovatus, B. plebeius, and B. uniformis. Among breast-fed infants, the prevalence of B. uniformis was higher in those with low genetic risk than in those with high genetic risk. Among formula-fed infants, the prevalence of B. ovatus and B. plebeius was increased in those with low genetic risk, while the prevalence of B. vulgatus was higher in those with high genetic risk. The results indicate that both the type of milk feeding and the HLA-DQ genotype influence the colonization process of Bacteroides species, and possibly the disease risk.

Zonulin and its regulation of intestinal barrier function: the biological door to inflammation, autoimmunity, and cancer

The primary functions of the gastrointestinal tract have traditionally been perceived to be limited to the digestion and absorption of nutrients and to electrolytes and water homeostasis. A more attentive analysis of the anatomic and functional arrangement of the gastrointestinal tract, however, suggests that another extremely important function of this organ is its ability to regulate the trafficking of macromolecules between the environment and the host through a barrier mechanism. Together with the gut-associated lymphoid tissue and the neuroendocrine network, the intestinal epithelial barrier, with its intercellular tight junctions, controls the equilibrium between tolerance and immunity to non-self antigens. Zonulin is the only physiological modulator of intercellular tight junctions described so far that is involved in trafficking of macromolecules and, therefore, in tolerance/immune response balance. When the finely tuned zonulin pathway is deregulated in genetically susceptible individuals, both intestinal and extraintestinal autoimmune, inflammatory, and neoplastic disorders can occur. This new paradigm subverts traditional theories underlying the development of these diseases and suggests that these processes can be arrested if the interplay between genes and environmental triggers is prevented by reestablishing the zonulin-dependent intestinal barrier function. This review is timely given the increased interest in the role of a "leaky gut" in the pathogenesis of several pathological conditions targeting both the intestine and extraintestinal organs.

Dietary strategies of immunomodulation in infants at risk for celiac disease

Celiac disease is an inflammatory disorder of the small intestine, triggered by the ingestion of gluten proteins contained in wheat, barley or rye, in genetically susceptible individuals. This disorder is considered to be mainly mediated by cellular immunity and restricted to the human leucocyte antigen-DQ presentation of gluten-derived toxic peptides to T-cells. Moreover, the involvement of innate immunity has been recently demonstrated to be necessary also for the development of intestinal tissue damage. Genetic susceptibility accounts for an uncertain proportion of the disease risk and gluten introduction works as the precipitating factor. However, currently, the research interest is also focused on environmental factors and gene–environment interactions, especially during the first months of life, which might help explain the onset of the disease. Infectious and dietary factors that could modulate the immune response orientating it either towards tolerance or intolerance/autoimmunity are the focus of primary attention. A significant number of studies have looked into the protective effect of breast-feeding against the disease. It is generally accepted that breast-feeding during the introduction of dietary gluten and increasing the duration of breast-feeding are associated with reduced risk of developing celiac disease. However, it is still not fully established whether breast-feeding truly protects with permanent tolerance acquisition or only reduces the symptoms and delays the diagnosis. Moreover, the timing and dose of gluten introduction also seem to be relevant and long-term prospective cohort studies are being carried out in order to elucidate its role in celiac disease development.

Celiac disease and the gluten-free diet

Celiac disease (CD) is now recognized as one of the most common genetic diseases of humankind. Furthermore, and contrary to previous opinion that categorized CD as a primarily pediatric disorder, CD can occur at any age and can present with a wide range of clinical manifestations. Missed and delayed CD diagnoses are common for a number of reasons, one of which is a lack of CD awareness among primary healthcare clinicians. The purpose of this article is to increase clinicians’ knowledge and awareness of CD.

A deregulated immune response to gliadin causes a decreased villus height in DQ8 transgenic mice

Celiac disease (CD) is an enteropathy triggered by gluten and mediated by CD4+ T cells. A complete understanding of CD immunopathogenesis has been hindered due to the lack of adequate in vivo models. Here, we explored the effect of the inhibition of COX by indomethacin in wheat gliadin-sensitized transgenic mice expressing the HLA-DQ8 heterodimer, a molecule associated with CD. Treated mice showed a gliadin-specific immune response with a significant reduction of villus height, not linked to crypt hyperplasia and to expansion of intraepithelial T cells. Notably, treated mice showed increased numbers of CD25+ and apoptotic cells in the lamina propria, whereas high basal levels of IFN-gamma secretion, along with a reduced gliadin-specific IL-2 expression were detected in MLN. Biochemical assessment of the lesion revealed increased mRNA of Lamb3 and Adamts2, encoding for ECM proteins, and enhanced activities of metalloproteinases MMP1, 2 and 7. We conclude that an intestinal sensitivity to gliadin, in connection with COX inhibition, caused a decreased villus height in DQ8 tg mice. The lesion was induced by a deregulated mucosal cell immunity to gliadin, thus triggering activation of a specific ECM protein pathway responsible for lamina propria remodeling.

Pediatric celiac disease

PURPOSE OF REVIEW

Celiac disease is an extremely common, although underdiagnosed, disorder. Knowledge about the varied clinical manifestations and the proper approach to screening and diagnosing celiac disease will lead to appropriate early intervention in affected children

RECENT FINDINGS

New age-dependent algorithms are emerging to properly screen for celiac disease. There is new evidence on the patchy nature of celiac disease supporting the practice of multiple duodenal biopsies including the bulb of the duodenum. Therapeutic dietary compliance, particularly in asymptomatic children, can be poor, and therefore, the involvement of a dietician trained in celiac disease is instrumental in keeping patients up to date with dietary guidelines and to improve their compliance to the diet. Expanding knowledge about the pathogenesis of celiac disease has led to the development of investigational therapeutic alternatives to the gluten-free diet. Ongoing clinical trials are evaluating methods of celiac disease prevention in at-risk infants.

SUMMARY

This review aims at outlining the different manifestations of celiac disease in children as well as a step-wise approach to screen and diagnose the disease. A better understanding of the pathogenic mechanisms of celiac disease is paving the way to innovative diagnostic tools, preventive strategies, and therapeutic interventions alternative to a gluten-free diet.

Long-term effect of gluten-free diet on growth velocity in Turkish children with celiac disease

We sought to analyze the long-term growth in children with celiac disease (CD) as well as the association of height and weight SD score at the end of 4 years with the demographic and clinical presentation at initial admission. Thirty-four children with CD were enrolled in the study and followed for at least 4 years. Patients were divided into three groups (Group 1: patients <or=5 years old, Group 2: patients 5-10 years old, and Group 3: patients >10 years, at the time of diagnosis). Patients' charts were reviewed for demographic and clinical features at initial admission. Anthropometric measurements at initial admission, at 6th months, and 1st, 2nd, 3rd, and 4th years were recorded. Gluten-free diet led to rapid increase in weight SD and height SD score in patients <or=5 years old at the time of diagnosis (Group 1). Increment in height SD score was the highest in patients 5-10 years old (Group 2) at the end of 4 years. A negative correlation was found between age at the time of diagnosis and weight and height SD score at the end of 4 years (r = -0.503, P = 0.03 and r = -0.554, P = 0.01). Multiple regression analysis revealed that height SD score at the end of the 4 years was associated with age at the time of diagnosis. The other factors had no effect on the weight and height SD score at the end of 4 years. Early diagnosis and good adhesion to a gluten-free diet are essential for long-term growth in CD. Celiac societies and the mass media must expand an effort to educate the community regarding the symptoms of the disease.

Seasonality of birth month of children with celiac disease differs from that in the general population and between sexes and is linked to family history and environmental factors

BACKGROUND

Patients with autoimmune diseases, such as type 1 diabetes mellitus, atopic dermatitis, autoimmune thyroid diseases, and multiple sclerosis have a different seasonality of month of birth (MOB) from the general population. This study was undertaken to determine the seasonality of MOB in children with celiac disease (CD), an autoimmune-mediated enteropathy.

PATIENTS AND METHODS

The medical records of 431 children with CD (239 girls, 192 boys) were included in the study; 138 girls and 81 boys were under the age of 24 months. Data were analyzed by the cosinor method, which, in addition to statistical significance, provides parameters of rhythms. Statistical differences between groups were also analyzed by the chi test.

RESULTS

Patients with CD showed different patterns from that in the general population, which peaks in September. Boys and girls with CD were found to have a different seasonality of MOB (P < 0.02). Girls whose CD was diagnosed before age 24 months (peak July-August) had a different seasonality of MOB from those whose CD was diagnosed after age 24 months (no rhythm; P < 0.005) and showed a different seasonality from boys whose CD was diagnosed above 24 months (peak July; P < 0.02). In addition, we found a different seasonality of MOB in children with a family history of CD compared with those with no family history (P < 0.001).

CONCLUSIONS

Girls with the diagnosis of CD and patients of both sexes with a family history of CD have a different pattern of seasonality of birth from the general population. This is suggestive of a perinatal virus infection as a plausible candidate for the primary trigger.

Possible pathogenetic role of vascular, immunological and genetic factors in certain gastoenterological disorders

A coeliakia és a gyulladásos bélbetegségek (IBD) változatos klinikai megjelenését befolyásoló faktorok jelentős része ismeretlen. A haptoglobin (Hp) molekula három fő fenotípusa eltérő antioxidáns, scavenger és immunmoduláns tulajdonsággal rendelkezik. Nagyszámú coeliakiás és IBD-betegben vizsgáltuk a Hp-polimorfizmus megoszlását és a betegség klinikai megjelenésével való lehetséges kapcsolatát. A Hp-fenotípusokat szérumból nátrium-dodecil-szulfát poliakrilamid gélelektroforézis (SDS-PAGE) és immunblottal határoztuk meg, amely egyértelműen azonosítja a genotípust is. Coeliakiában a kontrollpopulációhoz képest a Hp 2-1 fenotípus előfordulása szignifikánsan gyakoribb volt, míg a Hp 2-2 ritkább. A Hp 2-2 esetén azonban a súlyos, malabszorpcióval jelentkező klinikai betegség kockázata magasabb volt, míg a silent betegségé jóval alacsonyabb. Crohn-betegekben (CD) a Hp 2-1 fenotípus esetén a gyulladásos betegségforma előfordulása szignifikánsan gyakoribb volt a másik két Hp-fenotípushoz viszonyítva, míg a stenotizáló formáé ritkább. Primer szklerotizáló cholangitisben a Hp 1-1 fenotípus nem fordult elő. A Hp szerepét az immunreakciókban betöltött modulálóhatásai és eltérő térszerkezete magyarázhatja. A mikrobiális és autoantigének elleni szerológiai válasz segítséget jelenthet az IBD differenciáldiagnosztikájában, és összefüggést mutat a betegség fenotípusával. Nagyszámú IBD-betegben vizsgáltuk az anti- Saccharomyces cerevisiae (ASCA) és külső membránporin elleni antitestek (anti-Omp) enzimmel kapcsolt immunoszorbens assay (ELISA), illetőleg az atípusos perinukleáris antineutrophil citoplazmatikus antitest (P-ANCA) (indirekt immunfluoreszcencia) előfordulási gyakoriságát és a betegség fenotípusával való lehetséges kapcsolatukat. A szerológiai markerek hasznosnak bizonyultak az IBD differenciáldiagnosztikájában. CD-ben az ASCA- és az anti-Omp-pozitivitás a vékonybél-érintettség és a nem gyulladásos betegségforma szempontjából logisztikus regressziós analízisben is független rizikófaktornak bizonyult, míg a műtéti kockázat tekintetében nem. A nem gyulladásos típusú vékonybél-CD és az antimikrobiális antitest pozitivitásainak száma, illetőleg az antitesttiterek között szintén pozitív korrelációt találtunk (szerológiai-dózis hatás). Továbbá ASCA és az anti-Omp-antitestek jelenléte kapcsolatot mutatott a nucleotid oligomerizációs domén (NOD2/CARD15) genotípussal, és előfordulási gyakoriságuk szignifikánsan nőtt a NOD2/CARD15 mutációk számának növekedésével, ami gén-dózis hatásra utal és alátámasztja a mikrobákkal szembeni megváltozott érzékelés szerepét a CD patogenezisében.

Celiac disease: its implications for orthopaedic nursing

Celiac disease (CD), also known as gluten-sensitive enteropathy, is an inherited autoimmune disease that can lead to multisystem effects. Left undiagnosed and untreated, it has severe orthopaedic implications involving osteoporosis and unnecessary treatment of joint pain, which could be avoided. The orthopaedic nurse may have thought that CD was primarily an abdominal disorder. We need to be aware of the potential practice implications in orthopaedics by understanding the disease, its diagnosis, and treatment. Furthermore, orthopaedic nurses can contribute to current research by studying the relationships between CD and orthopaedic problems.

Antagonist peptides of the gliadin T-cell stimulatory sequences: a therapeutic strategy for celiac disease

Celiac disease (CD) is a T helper 1-driven autoimmune permanent enteropathy, triggered in susceptible individuals by the ingestion of gluten, the alcohol-soluble protein fraction of some cereals, such as wheat, rye, and barley. The only available treatment for CD is the life-long withdrawal of gluten-containing foods from the diet. Complying with gluten-free diet is difficult and affects the quality of life. Therefore, alternative therapies are being investigated. In this paper, we review a new therapeutic strategy for CD, relying upon peptides that are analogs of gliadin T-cell epitopes that show the ability to down-modulate the immune response pathogenic of CD. These peptides have been obtained artificially by amino acids substitution of gliadin T-cell stimulatory sequences and an immunomodulatory sequence has been identified in the alcohol-soluble protein fraction of cultivars of durum wheat.

Advances in celiac disease and gluten-free diet

Celiac disease is becoming an increasingly recognized autoimmune enteropathy caused by a permanent intolerance to gluten. Once thought to be a rare disease of childhood characterized by diarrhea, celiac disease is actually a multisystemic disorder that occurs as a result of an immune response to ingested gluten in genetically predisposed individuals. Screening studies have revealed that celiac disease is most common in asymptomatic adults in the United States. Although considerable scientific progress has been made in understanding celiac disease and in preventing or curing its manifestations, a strict gluten-free diet is the only treatment for celiac disease to date. Early diagnosis and treatment, together with regular follow-up visits with a dietitian, are necessary to ensure nutritional adequacy and to prevent malnutrition while adhering to the gluten-free diet for life. The purpose of this review is to provide clinicians with current updated information about celiac disease, its diverse clinical presentation and increased prevalence, the complex pathophysiology and strong genetic predisposition to celiac disease, and its diagnosis. This review focuses in detail on the gluten-free diet and the importance of intense expert dietary counseling for all patients with celiac disease. Recent advances in the gluten-free diet include food allergen labeling as well as the US Food and Drug Administration's proposed definition of the food-labeling term gluten-free. The gluten-free diet is complex and patients need comprehensive nutrition education from a skilled dietitian.

Haptoglobin polymorphism: a novel genetic risk factor for celiac disease development and its clinical manifestations

BACKGROUND

Haptoglobin (Hp) alpha-chain alleles 1 and 2 account for 3 phenotypes that may influence the course of inflammatory diseases via biologically important differences in their antioxidant, scavenging, and immunomodulatory properties. Hp1-1 genotype results in the production of small dimeric, Hp2-1 linear, and Hp2-2 cyclic polymeric haptoglobin molecules. We investigated the haptoglobin polymorphism in patients with celiac disease and its possible association to the presenting symptoms.

METHODS

We studied 712 unrelated, biopsy-proven Hungarian celiac patients (357 children, 355 adults; severe malabsorption 32.9%, minor gastrointestinal symptoms 22.8%, iron deficiency anemia 9.4%, dermatitis herpetiformis 15.6%, silent disease 7.2%, other 12.1%) and 384 healthy subjects. We determined haptoglobin phenotypes by gel electrophoresis and assigned corresponding genotypes.

RESULTS

Hp2-1 was associated with a significant risk for celiac disease (P = 0.0006, odds ratio [OR] 1.54, 95% CI 1.20-1.98; prevalence 56.9% in patients vs 46.1% in controls). It was also overrepresented among patients with mild symptoms (69.2%) or silent disease (72.5%). Hp2-2 was less frequent in patients than in controls (P = 0.0023), but patients having this phenotype were at an increased risk for severe malabsorption (OR 2.21, 95% CI 1.60-3.07) and accounted for 45.3% of all malabsorption cases. Celiac and dermatitis herpetiformis patients showed similar haptoglobin phenotype distributions.

CONCLUSIONS

The haptoglobin polymorphism is associated with susceptibility to celiac disease and its clinical presentations. The predominant genotype in the celiac population was Hp2-1, but Hp2-2 predisposed to a more severe clinical course. The phenotype-dependent effect of haptoglobin may result from the molecule's structural and functional properties.

Transamidation of wheat flour inhibits the response to gliadin of intestinal T cells in celiac disease

BACKGROUND & AIMS

Celiac disease is characterized by activation of HLA-DQ2/DQ8-restricted intestinal gluten-specific CD4(+) T cells. In particular, gluten becomes a better T-cell antigen following deamidation catalyzed by tissue transglutaminase. To date, the only available therapy is represented by adherence to a gluten-free diet. Here, we examined a new enzyme strategy to preventively abolish gluten activity.

METHODS

Enzyme modifications of the immunodominant alpha-gliadin peptide p56-68 were analyzed by mass spectrometry, and peptide binding to HLA-DQ2 was simulated by modeling studies. Wheat flour was treated with microbial transglutaminase and lysine methyl ester; gliadin was subsequently extracted, digested, and deamidated. Gliadin-specific intestinal T-cell lines (iTCLs) were generated from biopsy specimens from 12 adult patients with celiac disease and challenged in vitro with different antigen preparations.

RESULTS

Tissue transglutaminase-mediated transamidation with lysine or lysine methyl ester of p56-68 or gliadin in alkaline conditions inhibited the interferon gamma expression in iTCLs; also, binding to DQ2 was reduced but not abolished, as suggested by in silico analysis. Lysine methyl ester was particularly effective in abrogating the activity of gliadin. Notably, a block in the response was observed when iTCLs were challenged with gliadin extracted from flour pretreated with microbial transglutaminase and lysine methyl ester.

CONCLUSIONS

Transamidation of wheat flour with a food-grade enzyme and an appropriate amine donor can be used to block the T cell-mediated gliadin activity. Considering the crucial role of adaptive immunity in celiac disease, our findings highlight the potential of the proposed treatment to prevent cereal toxicity.