Morphometric studies in duodenal biopsies from patients with coeliac disease: the effect of the steroid fluticasone propionate

Old and New Adjunctive Therapies in Celiac Disease and Refractory Celiac Disease: A Review

Celiac disease (CD) is a chronic enteropathy caused by the ingestion of gluten in a genetically susceptible individual. Currently, a gluten-free diet (GFD) is the only recommended treatment. However, unintentional gluten ingestion or a persistent villous atrophy with malabsorption (regardless of a strict GFD) as in the case of Refractory Celiac Disease (RCD) represents a major issue. In this review, we have analysed and discussed data from both randomized controlled trials and observational studies concerning adjunctive therapies as well as novel therapies for the treatment of CD and RCD. The literature search was carried out through Medline and Scopus. In total, 2268 articles have been identified and 49 were included in this review (36 studies resulting from the search strategy and 13 from other sources). Today, GFD remains the only effective treatment, although steroids, mesalamine, and more recently biological therapies have found space in the complex management of RCD. Currently, studies evaluating the effectiveness of novel therapies are still limited and preliminary results have been controversial.

Quantitation of intraepithelial lymphocytes in human duodenum: what is normal?

BACKGROUND

An increase in intraepithelial lymphocytes (IELs) is mandatory for the histological diagnosis of coeliac disease (CD). Currently, duodenal biopsies are used almost exclusively to establish the diagnosis, yet published work continues to cite an upper limit of 40 lymphocytes/100 epithelial cells, a figure derived from jejunal biopsies over 30 years ago.

AIM

To establish the normal range for IEL counts in distal duodenal biopsies.

MATERIALS/METHODS

Twenty subjects (seven men, 13 women; median age, 34 years; range, 20-65) with a normal sugar permeability test and concurrent distal duodenal biopsies were identified. The number of IELs and epithelial cell nuclei in an uninterrupted length of surface (villous) epithelium (> 500 cells) was counted. An image analysis system was used to assess villous architecture by calculating the villous height to crypt depth ratio.

RESULTS

The range of IEL counts in 20 subjects was 1.8-26/100 villous epithelial cells, with a mean value of 11 and SD of 6.8. The mean villous to crypt ratio was 1.82 (SD, 0.38; range, 1.22-2.46). There was no correlation between IEL counts and villous to crypt ratio (Spearman rank correlation, -0.066; p = 0.80).

CONCLUSIONS

These results suggest that 25 IELs/100 epithelial cells (mean +2 SD) should be taken as the upper limit of the normal range for duodenal mucosa.

Prospective significance of antiendomysium antibody positivity in subsequently verified celiac disease

BACKGROUND

In order to assess their long-term predictability for the diagnosis of celiac disease, antiendomysium antibody results were compared with the outcome of the Interlaken diagnostic process.

METHODS

Prospective gluten challenge was performed in 153 children with previously diagnosed flat small-intestine mucosa. In 90 patients (Group A), endomysium antibodies were initially positive, in seven (Group B) they were negative, and 56 patients (Group C) had no initial serological results. In IgA-deficient persons, IgG antibodies were also assayed, both by the immunofluorescent method.

RESULTS

Histological relapse rates were 100% (90/90), 14.3% (1/7), and 76.8% (43/56), p < 0.001, in Groups A, B, and C, respectively. Each patient with relapse also exhibited endomysium antibody positivity during the challenge. Patients in whom celiac disease could be finally ruled out remained consistently endomysium-antibody negative. The celiac disease patient in Group B had severe secondary immunoglobulin deficiency at entry, which explained the initial negativity. Diagnosis based on antiendomysium antibody positivity and flat mucosa gave a higher applicability (92.8 vs. 50.3%) and reliability (relapse rate 100 vs. 89.6%) than the 1990 European Society of Paediatric Gastroenterology and Nutrition (ESPGAN) criteria among these patients.

CONCLUSIONS

Endomysium antibody positivity at presentation has been found to be as useful as gluten challenge in the diagnosis of celiac disease, even in patients under the age of 2 years. Challenge is still advisable in patients with a flat small intestinal mucosa when antiendomysium antibody results are negative or have not been done, as among these patients significantly lower relapse rates were found.

Effect of dietary nucleotides on small intestinal repair after diarrhoea. Histological and ultrastructural changes

The effects of specific nutrients on intestinal maturation and repair after injury are practically unknown. The purpose of this work was to study the effects of dietary nucleotides on the repair of the intestinal mucosa after chronic diarrhoea induced by a lactose enriched diet in the weanling rat. One group of weanling rats was fed with a standard semipurified diet (control group), and another group was fed with the same diet containing lactose as the only soluble carbohydrate (lactose group). After 14 days the lactose group was allowed to recover for four weeks with the control diet (lactose-control group) or with the control diet supplemented with AMP, GMP, IMP, CMP, and UMP 50 mg/100 g each (lactose-nucleotide group). The control group was divided into two subgroups, which were fed with the control diet and the nucleotide supplemented diet for the same period (control-control group and control-nucleotide group). The lactose diet induced diarrhoea after 24 hours of feeding. Two weeks later there were changes in intestinal structure with loss of enterocyte microvillar surface, significant lymphocyte infiltration, supranuclear cytoplasmic vesiculation, decreased number of goblet cells, and enlarged mitochondria with low density and few cristae. After recovery from diarrhoea, animals fed the nucleotide enriched diet showed an intestinal histology and ultrastructure closer to that of the normal control group. Mitochondrial ultrastructure was closer to normal in comparison with the lactose-control diet group. In this second group the number of goblet cells as well as the villous height/crypt depth ratio was reduced and the number of intraepithelial lymphocytes increased compared with the nucleotide supplemented group. These results suggest that dietary nucleotides may be important nutrients for intestinal repair.