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Zingone F, Maimaris S, Auricchio R, Caio GPI, Carroccio A, Elli L, Galliani E, Montagnani M, Valiante F, Biagi F. Guidelines of the Italian societies of gastroenterology on the diagnosis and management of coeliac disease and dermatitis herpetiformis. Dig Liver Dis 2022; 54:1304-1319. [PMID: 35858884 DOI: 10.1016/j.dld.2022.06.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/11/2022] [Accepted: 06/19/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Coeliac disease and dermatitis herpetiformis are immune-mediated diseases triggered by the consumption of gluten in genetically predisposed individuals. These guidelines were developed to provide general practitioners, paediatricians, gastroenterologists, and other clinicians with an overview on the diagnosis, management and follow-up of coeliac patients and those with dermatitis herpetiformis. METHODS Guidelines were developed by the Italian Societies of Gastroenterology. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists and a paediatrician with expertise in this field. RESULTS These guidelines provide a practical guidance for the diagnosis, management and follow-up of coeliac patients and dermatitis herpetiformis in children and adults, both in primary care and in specialist settings. We developed four sections on diagnosis, gluten-free diet, follow-up and risk of complications in adults, one section focused on diagnosis and follow-up in children and one on the diagnosis and management of dermatitis herpetiformis. CONCLUSIONS These guidelines may support clinicians to improve the diagnosis and management of patients with coeliac disease.
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Affiliation(s)
- Fabiana Zingone
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy; Gastroenterology Unit, Azienda Ospedale Università, Padova, Italy.
| | - Stiliano Maimaris
- Dipartimento di Medicina Interna e Terapia Medica, Università di Pavia, Italia
| | - Renata Auricchio
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Giacomo Pietro Ismaele Caio
- Department of Morphology, Surgery and Experimental Medicine, St. Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Antonio Carroccio
- Unit of Internal Medicine, "V. Cervello" Hospital, Ospedali Riuniti "Villa Sofia-Cervello", 90146 Palermo, University of Palermo, Italy
| | - Luca Elli
- Gastroenterology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Ermenegildo Galliani
- UOC Gastroenterologia ed Endoscopia Digestiva, AULSS1 Dolomiti Veneto, Ospedale San Martino, Belluno, Italy
| | - Marco Montagnani
- Department of Medical and Surgical Sciences, University of Bologna, Italy; Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Flavio Valiante
- UOC Gastroenterologia ed Endoscopia Digestiva, AULSS1 Dolomiti Veneto, Feltre (BL), Italy
| | - Federico Biagi
- Istituti Clinici Maugeri, IRCCS, Unità di Gastroenterologia dell'Istituto di Pavia, Italy
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Tye‐Din JA. Review article: Follow-up of coeliac disease. Aliment Pharmacol Ther 2022; 56 Suppl 1:S49-S63. [PMID: 35815829 PMCID: PMC9542881 DOI: 10.1111/apt.16847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/12/2022] [Accepted: 02/13/2022] [Indexed: 12/09/2022]
Abstract
Coeliac disease is a lifelong immune-mediated enteropathy with systemic features associated with increased morbidity and modestly increased mortality. Treatment with a strict gluten-free diet improves symptoms and mucosal damage but is not curative and low-level gluten intake is common despite strict attempts at adherence. Regular follow-up after diagnosis is considered best-practice however this is executed poorly in the community with the problem compounded by the paucity of data informing optimal approaches. The aim of dietary treatment is to resolve symptoms, reduce complication risk and improve quality of life. It follows that the goals of monitoring are to assess dietary adherence, monitor disease activity, assess symptoms and screen for complications. Mucosal disease remission is regarded a key measure of treatment success as healing is associated with positive health outcomes. However, persistent villous atrophy is common, even after many years of a gluten-free diet. As the clinical significance of asymptomatic enteropathy is uncertain the role for routine follow-up biopsies remains contentious. Symptomatic non-responsive coeliac disease is common and with systematic follow-up a cause is usually found. Effective models of care involving the gastroenterologist, dietitian and primary care doctor will improve the consistency of long-term management and likely translate into better patient outcomes. Identifying suitable treatment targets linked to long-term health is an important goal.
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Affiliation(s)
- J. A. Tye‐Din
- Immunology DivisionThe Walter and Eliza Hall InstituteParkvilleVictoriaAustralia,Department of Medical BiologyUniversity of MelbourneParkvilleVictoriaAustralia,Department of GastroenterologyThe Royal Melbourne HospitalParkvilleVictoriaAustralia,Centre for Food & Allergy ResearchMurdoch Children’s Research InstituteParkvilleVictoriaAustralia
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Greenaway EA, Raju SA, Sanders DS. Why Is There Medical Inertia and Nihilism to Celiac Disease? Comment on Pivetta et al. In Elderly Anemic Patients without Endoscopic Signs of Bleeding Are Duodenal Biopsies Always Necessary to Rule out Celiac Disease? Diagnostics 2022, 12, 678. Diagnostics (Basel) 2022; 12:diagnostics12071510. [PMID: 35885416 PMCID: PMC9318470 DOI: 10.3390/diagnostics12071510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/08/2022] [Accepted: 06/17/2022] [Indexed: 11/26/2022] Open
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Kröger S, Repo M, Hiltunen P, Vornanen M, Huhtala H, Kivelä L, Kurppa K. Differential diagnosis and long-term outcomes of non-atrophic duodenal changes in children. Front Pediatr 2022; 10:982623. [PMID: 36105857 PMCID: PMC9464825 DOI: 10.3389/fped.2022.982623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/11/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES AND STUDY Gastrointestinal endoscopy is often performed when investigating abdominal complaints in children. While atrophic changes of the duodenal mucosa are usually caused by celiac disease, the prevalence and clinical significance of non-atrophic duodenal changes are less clear. We studied these issues in a large pediatric endoscopic cohort. METHODS Comprehensive data on clinical features, diagnostic findings and long-term outcomes of children who had undergone upper gastrointestinal endoscopy with systematic duodenal sampling were collected. Study variables were compared between children with non-atrophic changes and normal histology, and between those with non-atrophic changes who did and did not receive a diagnosis. RESULTS The study comprised 1,170 consecutive children, of whom 51 (4.4%) had non-atrophic and 315 (26.9%) atrophic duodenal changes and 804 (68.7%) normal histology. The most common non-atrophic findings were non-specific inflammation (n = 19) and intraepithelial lymphocytosis (n = 14). Patients with non-atrophic changes presented more often with blood in stools (23.5 vs. 11.3%; p = 0.009), anemia (43.2 vs. 36.5%; p = 0.028) and positive celiac serology (34.3 vs. 12.9%; p < 0.001) than those with a normal duodenum. Twenty-four (44%) of those with non-atrophic changes received an initial diagnosis, the most common of which were inflammatory bowel disease (IBD) (n = 8), Helicobacter pylori infection (n = 3) and food allergy (n = 3). The prevalence of the diagnoses did not differ from those with a normal duodenum. Those who received a diagnosis had more often blood in stools (37.5 vs. 11.1%; p = 0.027), anemia (70.6 vs. 20.0%; p = 0.002) and negative celiac serology (50.0 vs. 7.7%; p = 0.013) than those without diagnosis. During a follow-up of 6.1-13.3 years, five of the 12 initially undiagnosed seropositive patients developed celiac disease, and one patient also developed ulcerative colitis. CONCLUSION Non-atrophic duodenal changes are relatively common and associated with anemia, blood in stools, and positive celiac disease serology. Excluding potential celiac disease, those without an initial diagnosis have a favorable long-term prognosis.
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Affiliation(s)
- Sofia Kröger
- Department of Pediatrics, Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere University, Tampere, Finland.,Celiac Disease Research Center, Tampere University, Tampere, Finland
| | - Marleena Repo
- Department of Pediatrics, Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere University, Tampere, Finland.,Celiac Disease Research Center, Tampere University, Tampere, Finland
| | - Pauliina Hiltunen
- Department of Pediatrics, Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere University, Tampere, Finland
| | - Martine Vornanen
- Department of Pathology, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Laura Kivelä
- Department of Pediatrics, Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere University, Tampere, Finland.,Celiac Disease Research Center, Tampere University, Tampere, Finland.,Children's Hospital and Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Kalle Kurppa
- Department of Pediatrics, Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University Hospital, Tampere University, Tampere, Finland.,Celiac Disease Research Center, Tampere University, Tampere, Finland.,Seinäjoki Central Hospital, University Consortium of Seinäjoki, Seinäjoki, Finland
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Gómez-Escudero O, Remes-Troche JM. Approach to the adult patient with chronic diarrhea: A literature review. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 86:387-402. [PMID: 34389290 DOI: 10.1016/j.rgmxen.2021.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/25/2021] [Indexed: 02/07/2023]
Abstract
Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.
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Affiliation(s)
- O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia y Motilidad Gastrointestinal, Hospital Ángeles Puebla, Puebla, Mexico.
| | - J M Remes-Troche
- Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
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Gómez-Escudero O, Remes-Troche JM. Approach to the adult patient with chronic diarrhea: a literature review. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2021; 86:S0375-0906(21)00038-0. [PMID: 34074557 DOI: 10.1016/j.rgmx.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 11/22/2022]
Abstract
Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.
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Affiliation(s)
- O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia y Motilidad Gastrointestinal, Hospital Ángeles Puebla, Puebla, México.
| | - J M Remes-Troche
- Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, México
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Fernández-Bañares F, Arau B, Raga A, Aceituno M, Tristán E, Carrasco A, Ruiz L, Martín-Cardona A, Ruiz-Ramírez P, Esteve M. Long-Term Effect of a Gluten-Free Diet on Diarrhoea- or Bloating-Predominant Functional Bowel Disease: Role of the 'Low-Grade Coeliac Score' and the 'Coeliac Lymphogram' in the Response Rate to the Diet. Nutrients 2021; 13:1812. [PMID: 34073569 PMCID: PMC8228436 DOI: 10.3390/nu13061812] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/19/2021] [Accepted: 05/25/2021] [Indexed: 12/12/2022] Open
Abstract
1. BACKGROUND The long-term effect of a gluten-free diet (GFD) on functional bowel disorders (FBDs) has been scarcely studied. The aim was to assess the effect of a GFD on FBD patients, and to assess the role of both the low-grade coeliac score and coeliac lymphogram in the probability of response to a GFD. 2. METHODS 116 adult patients with either predominant diarrhoea or abdominal bloating, fulfilling Rome IV criteria of FBD, were treated with a GFD. Duodenum biopsies were performed for both pathology studies and intraepithelial lymphocyte subpopulation patterns. Coeliac lymphogram was defined as an increase in TCRγδ+ cells plus a decrease in CD3- cells. A low-grade coeliac score >10 was considered positive. 3. RESULTS Sustained response to GFD was observed in 72 patients (62%) after a median of 21 months of follow-up, who presented more often with coeliac lymphogram (37.5 vs. 11.4%; p = 0.02) and a score >10 (32 vs. 11.4%; p = 0.027) compared to non-responders. The frequency of low-grade coeliac enteropathy was 19.8%. 4. CONCLUSION A GFD is effective in the long-term treatment of patients with previously unexplained chronic watery diarrhoea- or bloating-predominant symptoms fulfilling the criteria of FBD. The response rate was much higher in the subgroup of patients defined by the presence of both a positive low-grade coeliac score and coeliac lymphogram.
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Affiliation(s)
- Fernando Fernández-Bañares
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrassa, Spain; (B.A.); (A.R.); (M.A.); (E.T.); (A.C.); (L.R.); (A.M.-C.); (P.R.-R.); (M.E.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Beatriz Arau
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrassa, Spain; (B.A.); (A.R.); (M.A.); (E.T.); (A.C.); (L.R.); (A.M.-C.); (P.R.-R.); (M.E.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Agnès Raga
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrassa, Spain; (B.A.); (A.R.); (M.A.); (E.T.); (A.C.); (L.R.); (A.M.-C.); (P.R.-R.); (M.E.)
| | - Montserrat Aceituno
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrassa, Spain; (B.A.); (A.R.); (M.A.); (E.T.); (A.C.); (L.R.); (A.M.-C.); (P.R.-R.); (M.E.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Eva Tristán
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrassa, Spain; (B.A.); (A.R.); (M.A.); (E.T.); (A.C.); (L.R.); (A.M.-C.); (P.R.-R.); (M.E.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Anna Carrasco
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrassa, Spain; (B.A.); (A.R.); (M.A.); (E.T.); (A.C.); (L.R.); (A.M.-C.); (P.R.-R.); (M.E.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Laura Ruiz
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrassa, Spain; (B.A.); (A.R.); (M.A.); (E.T.); (A.C.); (L.R.); (A.M.-C.); (P.R.-R.); (M.E.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Albert Martín-Cardona
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrassa, Spain; (B.A.); (A.R.); (M.A.); (E.T.); (A.C.); (L.R.); (A.M.-C.); (P.R.-R.); (M.E.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Pablo Ruiz-Ramírez
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrassa, Spain; (B.A.); (A.R.); (M.A.); (E.T.); (A.C.); (L.R.); (A.M.-C.); (P.R.-R.); (M.E.)
| | - Maria Esteve
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, 08221 Terrassa, Spain; (B.A.); (A.R.); (M.A.); (E.T.); (A.C.); (L.R.); (A.M.-C.); (P.R.-R.); (M.E.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
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Ruiz-Ramírez P, Carreras G, Fajardo I, Tristán E, Carrasco A, Salvador I, Zabana Y, Andújar X, Ferrer C, Horta D, Loras C, García-Puig R, Fernández-Bañares F, Esteve M. Intraepithelial Lymphocyte Cytometric Pattern Is a Useful Diagnostic Tool for Coeliac Disease Diagnosis Irrespective of Degree of Mucosal Damage and Age-A Validation Cohort. Nutrients 2021; 13:nu13051684. [PMID: 34063411 PMCID: PMC8155844 DOI: 10.3390/nu13051684] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction: The study of intraepithelial lymphocytes (IEL) by flow cytometry is a useful tool in the diagnosis of coeliac disease (CD). Previous data showed that an increase in %TCRγδ+ and decrease of %CD3− IEL constitute a typical CD cytometric pattern with a specificity of 100%. However, there are no data regarding whether there are differences in the %TCRγδ+ related to sex, age, titers of serology, and degree of histological lesion. Study aims: To confirm the high diagnostic accuracy of the coeliac cytometric patterns. To determine if there are differences between sex, age, serology titers, and histological lesion grade. Results: We selected all patients who fulfilled “4 of 5” rule for CD diagnosis (n = 169). There were no differences in %TCRγδ+ between sexes (p = 0.909), age groups (p = 0.986), serology titers (p = 0.53) and histological lesion grades (p = 0.41). The diagnostic accuracy of complete CD cytometric pattern was: specificity 100%, sensitivity 82%, PPV 100%, NPV 47%. Conclusion: We confirmed, in a validation cohort, the high diagnostic accuracy of complete CD pattern irrespective of sex, age, serology titers, and grade of mucosal lesion.
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Affiliation(s)
- Pablo Ruiz-Ramírez
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
| | - Gerard Carreras
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
| | - Ingrid Fajardo
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
| | - Eva Tristán
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Anna Carrasco
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Isabel Salvador
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
| | - Yamile Zabana
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Xavier Andújar
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Carme Ferrer
- Department of Pathology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain;
| | - Diana Horta
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
| | - Carme Loras
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Roger García-Puig
- Department of Pediatrics, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain;
| | - Fernando Fernández-Bañares
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Maria Esteve
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, 08221 Barcelona, Spain; (P.R.-R.); (G.C.); (I.F.); (E.T.); (A.C.); (I.S.); (Y.Z.); (X.A.); (D.H.); (C.L.); (F.F.-B.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-937365050
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Bosch DE, Liu YJ, Truong CD, Lloyd KA, Swanson PE, Upton MP, Yeh MM. Duodenal intraepithelial lymphocytosis in Helicobacter pylori gastritis: comparison before and after treatment. Virchows Arch 2021; 478:805-809. [PMID: 33025296 DOI: 10.1007/s00428-020-02941-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/09/2020] [Accepted: 09/27/2020] [Indexed: 12/12/2022]
Abstract
Our aims were to assess performance of duodenal intraepithelial lymphocyte counting for diagnosis of Helicobacter pylori (H. pylori) gastritis, and effects of eradication therapy on intraepithelial lymphocytosis. Paired duodenal and gastric biopsies from subjects with a pathologic diagnosis of H. pylori gastritis were reviewed. Higher duodenal intraepithelial lymphocyte counts were observed in 40 subjects with H. pylori gastritis (26 ± 5 per villus) than 52 subjects negative for H. pylori (12 ± 2 per villus). After successful eradication therapy, duodenal lymphocytes were indistinguishable from H. pylori-negative subjects, whereas they remained elevated after failed eradication therapy. This study confirms previous reports of increased duodenal intraepithelial lymphocytes in patients with concurrent Helicobacter pylori gastritis. Intraepithelial lymphocyte counts of > 15 per villus or > 10 per 100 enterocytes were predictive of infection. Duodenal lymphocytosis decreases significantly after successful eradication therapy but remains elevated when treatment fails.
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Affiliation(s)
- Dustin E Bosch
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, 1959 NE Pacific Street, NE140D, Box 356100, Seattle, WA, 98195-6100, USA
| | - Yong-Jun Liu
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, 1959 NE Pacific Street, NE140D, Box 356100, Seattle, WA, 98195-6100, USA
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Camtu D Truong
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, 1959 NE Pacific Street, NE140D, Box 356100, Seattle, WA, 98195-6100, USA
- Department of Pathology, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Kelly A Lloyd
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, 1959 NE Pacific Street, NE140D, Box 356100, Seattle, WA, 98195-6100, USA
- Northwest Pathology, Bellingham, WA, USA
| | - Paul E Swanson
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, 1959 NE Pacific Street, NE140D, Box 356100, Seattle, WA, 98195-6100, USA
| | - Melissa P Upton
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, 1959 NE Pacific Street, NE140D, Box 356100, Seattle, WA, 98195-6100, USA
| | - Matthew M Yeh
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, 1959 NE Pacific Street, NE140D, Box 356100, Seattle, WA, 98195-6100, USA.
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
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Brown I, Bettington M, Rosty C. The role of histopathology in the diagnosis and management of coeliac disease and other malabsorptive conditions. Histopathology 2020; 78:88-105. [PMID: 33382496 DOI: 10.1111/his.14262] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 12/17/2022]
Abstract
Most absorption of nutrients takes place in the proximal small intestine, and the most common disorders leading to malabsorption are associated with a morphological abnormality in the duodenal mucosa that is appreciable in histological sections of biopsy specimens. Coeliac disease is the most well-known example, causing intraepithelial lymphocytosis, inflammation and villous atrophy in the duodenum. Remarkably similar inflammatory changes can be induced by other processes, including medications, e.g. angiotensin II receptor blockers and immune checkpoint inhibitors, immune dysregulation disorders, e.g. common variable immunodeficiency and autoimmune enteropathy, infections, collagenous sprue, and tropical sprue. However, there are often subtle histological differences from coeliac disease in the type of inflammatory infiltrate, the presence of crypt apoptosis, and the extent and type of inflammation beyond the duodenum. The clinical setting and serological investigation usually allow diagnostic separation, but some cases remain challenging. Histopathology is also important in assessing the response to treatment, such as the change in villous architecture caused by a gluten-free diet, or the response to cessation of a potentially causative medication. This review examines the practical role that histopathology of duodenal biopsy specimens plays in the assessment and management of inflammatory malabsorptive processes of the proximal small intestine, with a particular emphasis on coeliac disease.
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Affiliation(s)
- Ian Brown
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Mark Bettington
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Christophe Rosty
- Envoi Specialist Pathologists, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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11
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Human Leukocyte Antigen (HLA) Haplotype Does Not Influence the Inflammatory Pattern of Duodenal Lymphocytosis Linked to Irritable Bowel Syndrome. ACTA ACUST UNITED AC 2020; 56:medicina56120660. [PMID: 33260434 PMCID: PMC7761368 DOI: 10.3390/medicina56120660] [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] [Received: 09/25/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 11/17/2022]
Abstract
Background and objectives: Duodenal lymphocytosis (DL) is a condition characterized by enhanced infiltration of intraepithelial lymphocytes (IELs) in the duodenal mucosa, and it can be linked to both gluten- and non-gluten-related diseases, such as irritable bowel syndrome (IBS). Materials and methods: We retrospectively selected patients with DL linked to IBS. Formalin-embedded biopsy samples of the duodenum were collected. CD3 lymphocyte immunohistochemistry was used for IELs. The real-time polymerase chain reaction was used to quantify the amount of mRNA coding for tissue transglutaminase 2 (tTG2), interferon-gamma (IFNγ), toll-like receptor 2 (TLR2), and myeloid differentiation primary response 88 (MyD88). All subjects underwent DQ2-8 haplotype analysis. Controls were represented by subjects with IBS without DL. Results: Thirty-two patients with IBS-DL were retrospectively recruited. Fourteen subjects (43.8%) had a DQ2-8 haplotype. DQ2-8 positive subjects had similar levels compared to negative ones for tTG2, IFNγ, TLR2, and MyD88. Cigarette smoke did not influence molecular expression in our study. Smokers had a statistically higher IELs count than non-smokers (54.2 ± 7.7 vs. 36.0 ± 8.8, p < 0.001). A significant, direct correlation between IELs and duodenal expression of IFNγ was found (r = 0.36, p = 0.04). Conclusions: IBS with DL showed higher expression of inflammatory markers than controls, but DQ2-8 haplotype did not seem to affect their expression. Smoking might increase IELs infiltration.
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12
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Volta U, Caio G, Ghirardi C, Lungaro L, Mansueto P, Carroccio A, De Giorgio R. Minimal Lesions of the Small Intestinal Mucosa: More than Morphology. Dig Dis Sci 2020; 65:2761-2768. [PMID: 32875530 DOI: 10.1007/s10620-020-06571-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Minimal lesions of the small bowel are mucosal changes characterized by an increased number of intraepithelial lymphocytes (with or without crypt hyperplasia) and normal villous architecture. Such changes are associated with a wide spectrum of conditions, ranging from food intolerances to infections, and from drugs to immune diseases, with different clinical profiles and manifestations, which complicates the formulation of a differential diagnosis. Patient history, symptom evaluation, and histopathology are the diagnostic features needed to establish a correct diagnosis. Physicians should assist pathologists in formulating a precise morphological evaluation by taking well-oriented small intestinal biopsies and collecting informative clinical findings that inform histopathology. In this current clinical controversy, the authors provide the reader with an appraisal of the small intestine minimal lesions through a careful analysis of the major conditions (e.g., celiac disease and other non-celiac disorders) responsible for such changes and their differential diagnosis. Also, we acknowledge that some of the diseases detailed in this article may progress from an early minimal lesion to overt mucosal atrophy. Thus, the timing of the diagnosis is of paramount importance.
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Affiliation(s)
- Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giacomo Caio
- Department of Morphology, Surgery and Experimental Medicine, St. Anna University Hospital, University of Ferrara, Ferrara, Italy
- Celiac Center and Mucosal Immunology and Biology Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Caterina Ghirardi
- Department of Morphology, Surgery and Experimental Medicine, St. Anna University Hospital, University of Ferrara, Ferrara, Italy
| | - Lisa Lungaro
- Department of Morphology, Surgery and Experimental Medicine, St. Anna University Hospital, University of Ferrara, Ferrara, Italy
| | - Pasquale Mansueto
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Antonio Carroccio
- Unit of Internal Medicine, "V. Cervello" Hospital, Ospedali Riuniti "Villa Sofia-Cervello", Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Roberto De Giorgio
- Department of Morphology, Surgery and Experimental Medicine, St. Anna University Hospital, University of Ferrara, Ferrara, Italy.
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Khan MR, Silvester JA, Sparks B, Hintze Z, Ediger T, Larson JJ, Hill I, Absah I. The Utility of IgA-Based Serologic Markers in Diagnosing Celiac Disease in Children 24 Months of Age or Younger. J Pediatr 2020; 224:158-161.e2. [PMID: 32593411 PMCID: PMC7819766 DOI: 10.1016/j.jpeds.2020.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/28/2020] [Accepted: 04/03/2020] [Indexed: 12/27/2022]
Abstract
Current screening guidelines in North America for celiac disease recommend additional IgG based testing for younger children. Our multicenter retrospective study showed that the anti-tissue transglutaminase IgA antibody test should be the recommended initial test in all children, including those ≤24 months of age.
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Affiliation(s)
- Muhammad Rehan Khan
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Division of Pediatric Gastroenterology & Hepatology, Rochester, MN.
| | | | - Brandon Sparks
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - Zackary Hintze
- Harvard Celiac Disease Program, Boston Children’s Hospital, Boston, MA
| | - Tracy Ediger
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - Joseph J. Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Ivor Hill
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - Imad Absah
- Division of Pediatric Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
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Abstract
The evaluation of gastrointestinal pathology in children often requires a different approach from that in adults. In this concise review, the authors outline 3 diagnostic challenges that are often encountered in daily practice; these include eosinophilic diseases, duodenal intraepithelial lymphocytosis with preserved villous architecture, and terminal ileal inflammation in the setting of idiopathic inflammatory bowel disease.
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Affiliation(s)
- Juan Putra
- Department of Laboratory Medicine and Pathobiology, University of Toronto, 555 University Avenue, Toronto, Ontario M5G1X8, Canada; Division of Pathology, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G1X8, Canada
| | - Jeffrey D Goldsmith
- Department of Pathology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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15
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Schiepatti A, Savioli J, Vernero M, Borrelli de Andreis F, Perfetti L, Meriggi A, Biagi F. Pitfalls in the Diagnosis of Coeliac Disease and Gluten-Related Disorders. Nutrients 2020; 12:nu12061711. [PMID: 32517378 PMCID: PMC7352902 DOI: 10.3390/nu12061711] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/30/2020] [Accepted: 06/02/2020] [Indexed: 02/07/2023] Open
Abstract
The spectrum of gluten-related disorders (GRD) has emerged as a relevant phenomenon possibly impacting on health care procedures and costs worldwide. Current classification of GRD is mainly based on their pathophysiology, and the following categories can be distinguished: immune-mediated disorders that include coeliac disease (CD), dermatitis herpetiformis (DH), and gluten ataxia (GA); allergic reactions such as wheat allergy (WA); and non-coeliac gluten sensitivity (NCGS), a condition characterized by both gastrointestinal and extra-intestinal symptoms subjectively believed to be induced by the ingestion of gluten/wheat that has recently gained popularity. Although CD, DH, and WA are well-defined clinical entities, whose diagnosis is based on specific diagnostic criteria, a diagnosis of NCGS may on the contrary be considered only after the exclusion of other organic disorders. Neither allergic nor autoimmune mechanisms have been found to be involved in NCGS. Mistakes in the diagnosis of GRD are still a relevant clinical problem that may result in overtreatment of patients being unnecessary started on a gluten-free diet and waste of health-care resources. On the basis of our clinical experience and literature, we aim to identify the main pitfalls in the diagnosis of CD and its complications, DH, and WA. We provide a practical methodological approach to guide clinicians on how to recognize and avoid them.
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Affiliation(s)
- Annalisa Schiepatti
- Gastroenterology Unit of IRCCS Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, 27100 Pavia, Italy; (M.V.); (F.B.d.A.); (F.B.)
- Correspondence: ; Tel.: +39-0382-592331
| | - Jessica Savioli
- Allergy and Immunology Unit of Pavia IRCCS Institute, Istituti Clinici Scientifici Maugeri, 27100 Pavia, Italy; (J.S.); (L.P.); (A.M.)
- First Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, 27100 Pavia, Italy
| | - Marta Vernero
- Gastroenterology Unit of IRCCS Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, 27100 Pavia, Italy; (M.V.); (F.B.d.A.); (F.B.)
- First Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, 27100 Pavia, Italy
| | - Federica Borrelli de Andreis
- Gastroenterology Unit of IRCCS Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, 27100 Pavia, Italy; (M.V.); (F.B.d.A.); (F.B.)
- First Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, 27100 Pavia, Italy
| | - Luca Perfetti
- Allergy and Immunology Unit of Pavia IRCCS Institute, Istituti Clinici Scientifici Maugeri, 27100 Pavia, Italy; (J.S.); (L.P.); (A.M.)
| | - Antonio Meriggi
- Allergy and Immunology Unit of Pavia IRCCS Institute, Istituti Clinici Scientifici Maugeri, 27100 Pavia, Italy; (J.S.); (L.P.); (A.M.)
| | - Federico Biagi
- Gastroenterology Unit of IRCCS Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, 27100 Pavia, Italy; (M.V.); (F.B.d.A.); (F.B.)
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Use of small-bowel capsule endoscopy in cases of equivocal celiac disease. Gastrointest Endosc 2020; 91:1312-1321.e2. [PMID: 31923404 DOI: 10.1016/j.gie.2019.12.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Seronegative villous atrophy (SNVA), raised intraepithelial lymphocytes (IELs), and crypt hyperplasia on duodenal histology can be secondary to celiac disease (CD) or other causes such as medications or infections. Our aims were to assess the role of small-bowel capsule endoscopy (SBCE) in these patients and to ascertain whether findings on SBCE at diagnosis can predict disease outcome. METHODS Patients (n = 177) with SNVA, IELs, ± crypt hyperplasia on duodenal histology were studied. These patients all had an equivocal diagnosis of CD. RESULTS Overall, 56 patients (31.6%) had a positive SBCE. Thirty-three patients (58.9%) had disease affecting the proximal third of the small bowel (SB). The diagnostic yield of SBCE was 40.0% (22 patients), 51.4% (18 patients), 27.0% (10 patients), and 14.0% (7 patients) in patients with an unknown cause for SNVA (SNVA-UO), patients with SNVA who responded to a gluten-free diet (SNVA-CD), patients with a known cause for SNVA, and patients with railed IELs ± crypt hyperplasia, respectively. In SNVA-UO, SBCE at diagnosis was more likely to be positive in patients with persistent SNVA (10, 90.9%) and persistent SNVA with lymphoproliferative features (4, 80.4%) than patients with spontaneous resolution of SNVA (8, 20.5%) (P = .0001). All patients in the SNVA-CD group who eventually developed adverse events had a positive SBCE (P = .022). They also had more extensive SB disease than those without adverse events (50% vs 1% P = .002). More extensive SB disease on SBCE correlated with a higher SNVA-related mortality in patients with SNVA-UO and SNVA-CD (P = .019). Severity of histology did not correlate with mortality (P = .793). CONCLUSIONS A positive SBCE at diagnosis predicts a worse outcome. More importantly, more extensive disease in these patients is associated with poor survival. Targeting patients with extensive disease at diagnosis with more aggressive therapy can help to improve prognosis.
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Capannolo A, Necozione S, Gabrieli D, Ciccone F, Sollima L, Melchiorri L, Viscido A, Frieri G. Duodenal lymphocytosis in functional dyspepsia. Arab J Gastroenterol 2019; 20:91-94. [PMID: 31175076 DOI: 10.1016/j.ajg.2019.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/23/2019] [Accepted: 05/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS Functional dyspepsia is an exclusion diagnosis requiring different tests, including endoscopy, often repeated over time. Duodenal biopsies are frequently resorted to, not rarely revealing duodenal microscopic inflammation. Aim of the study is to confirm a previously supposed role of antro-duodenal low-grade inflammation in functional dyspepsia, evaluating the frequency of duodenal lymphocytosis, H. pylori infection and their association in a group of patients with functional dyspepsia compared to asymptomatic control subjects. PATIENTS AND METHODS A cross-sectional, observational study has been conducted screening all the patients who underwent duodenal biopsies during upper endoscopy, in a 30 months period. All the patients without endoscopic lesions were analysed. The study group consisted of patients compatible with the diagnosis of functional dyspepsia (Rome III criteria). The control group consisted of healthy asymptomatic subjects in the population subjected to endoscopy. The presence of duodenal lymphocytosis and of H. pylori infection in the two groups was evaluated. RESULTS 216 patients were enrolled: 161 in the functional dyspepsia group and 55 as asymptomatic control group. The frequency of duodenal lymphocytosis was similar between cases and control groups (25.47% vs 25.45%; p = 0.99), as well as H. pylori infection (26.71% vs 23.64%; p = 0.78). Duodenal lymphocytosis was significantly associated with functional dyspepsia only in H. pylori positive dyspeptic patients (p = 0.047). 94% of the subjects with both lymphocytosis and H. pylori infection suffer from dyspepsia. Duodenal intraepithelial lymphocytosis is significantly associated with bloating (p = 0.0082). CONCLUSIONS In our cohort of dyspeptic patients, duodenal lymphocytosis is significantly associated with bloating and the simultaneous presence of duodenal lymphocytosis and H. pylori infection is significantly more prevalent than in control subjects.
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Affiliation(s)
- Annalisa Capannolo
- Gastroenterology Unit, Department of Life, Health, & Environmental Sciences, University of L'Aquila, 67100 L'Aquila, Italy.
| | - Stefano Necozione
- Clinical Epidemiology, Department of Life, Health, & Environmental Sciences, University of L'Aquila, 67100 L'Aquila, Italy
| | - Dolores Gabrieli
- Gastroenterology Unit, Department of Life, Health, & Environmental Sciences, University of L'Aquila, 67100 L'Aquila, Italy
| | - Fabiana Ciccone
- Gastroenterology Unit, Department of Life, Health, & Environmental Sciences, University of L'Aquila, 67100 L'Aquila, Italy
| | - Laura Sollima
- Pathology Unit, San Salvatore Hospital, 67100 L'Aquila, Italy
| | | | - Angelo Viscido
- Gastroenterology Unit, Department of Life, Health, & Environmental Sciences, University of L'Aquila, 67100 L'Aquila, Italy
| | - Giuseppe Frieri
- Gastroenterology Unit, Department of Life, Health, & Environmental Sciences, University of L'Aquila, 67100 L'Aquila, Italy
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A Scoring System for Identifying Patients Likely to Be Diagnosed with Low-Grade Coeliac Enteropathy. Nutrients 2019; 11:nu11051050. [PMID: 31083384 PMCID: PMC6566304 DOI: 10.3390/nu11051050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 04/26/2019] [Accepted: 05/08/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND & AIMS Determining whether patients with lymphocytic enteritis (LE) have coeliac disease is a challenge. We analysed the variables associated with a low-grade coeliac enteropathy diagnosis in patients with suspected coeliac disease but without villous atrophy, and developed a scoring system to identify them. METHODS We collected data from 2010 through to 2016 on patients with lymphocytic enteritis and persistent symptoms compatible with the clinical spectrum of coeliac disease. One hundred and four patients starting on a gluten-free diet (GFD) were included. Duodenal biopsies were collected before the GFD and analysed for numbers of CD3+ T-cell receptor gamma delta+ (TCRγδ+), and CD3- intraepithelial lymphocytes. We performed a logistic regression analysis to identify factors associated with a low-grade coeliac enteropathy diagnosis. RESULTS Sixty-two patients achieved clinical remission after the GFD. Fifty of these 62 patients were diagnosed with low-grade coeliac enteropathy. Multivariate analysis identified the presence of >25% intraepithelial lymphocytosis, HLA-DQ2.5, positive serology, and increased numbers of TCRγδ+ cells with a low-grade coeliac enteropathy diagnosis. We developed a scoring system that identified patients with an area under the ROC curve (AUC) of 0.91. Scores of >10 had 86% sensitivity and 85% specificity. CONCLUSION We developed a scoring system that identifies patients likely to be diagnosed with low-grade coeliac enteropathy with an AUC value of 0.91.
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Lagana SM, Bhagat G. Biopsy Diagnosis of Celiac Disease: The Pathologist's Perspective in Light of Recent Advances. Gastroenterol Clin North Am 2019; 48:39-51. [PMID: 30711210 DOI: 10.1016/j.gtc.2018.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Celiac disease is a common immune-mediated disorder that occurs in individuals with permissive genetics (HLA-DQ2/DQ8 genotype) following exposure to certain wheat proteins. The histopathologic manifestations of small intestinal mucosal injury (villus atrophy, crypt hyperplasia, and intraepithelial lymphocytosis) are well recognized. However, these findings are not specific for celiac disease, because they are observed in other small intestinal disorders. These mimics include common and rare entities, the list of which continues to grow. This article discusses the histopathology and differential diagnosis of celiac disease and provides the pathologist's perspective on biopsy adequacy, evaluation, and reporting in light of current knowledge.
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Affiliation(s)
- Stephen M Lagana
- Columbia University, New York Presbyterian Hospital, 622 West 168th Street, VC14-209, New York, NY 10032, USA.
| | - Govind Bhagat
- Columbia University, New York Presbyterian Hospital, 622 West 168th Street, VC14-228, New York, NY 10032, USA
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Parihar V, Stack R, Alakkari A, Breslin N, Ryan BM, Crowther S, McNamara D. Clinical Outcome of Patients with Raised Intraepithelial Lymphocytes with Normal Villous Architecture on Duodenal Biopsy. Digestion 2018; 95:288-292. [PMID: 28511171 DOI: 10.1159/000476061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 04/25/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The finding of a raised intraepithelial lymphocytes (IELs) count with normal villous architecture is of sufficient clinical importance to be reported in routine duodenal biopsies. AIM To study the clinical and demographic data of patients with isolated increased IELs on duodenal biopsy. METHODS A single-tertiary-centre retrospective study was carried out with a review of medical records of patients with increased IELs. Patients from 2012 to 2014, >18 years with at least one biopsy from the second part of the duodenum with increased IELs; defined as >25 IELs/100 enterocytes, with preserved villous architecture were identified from our histopathology database with exclusion of patients with coeliac disease (CD).Clinical and demographic data were recorded following a chart review. CD was diagnosed by the attending physician based on the Physician Global Assessment. Data was compared between groups using a Student t test and ORs were calculated as appropriate. Statistical significance was set a priori at p < 0.05. RESULTS Over 24 months, 6,244 patients were found to have duodenal biopsies and 114 (1.8%) had isolated increased IELs. Of the patients with increased IELs, the mean age was 50 years and 34 (30%) were male. Follow-up was available in 75 (65%) of these and CD was subsequently diagnosed in 32% (n = 24). CD was associated with the female gender (22 out of 24 vs. 39 out of 51, OR 7.5, older age 55 vs. 41 years, p < 0.04), and higher IEL count with an IEL of >40 in 11 out of 24 (46%) with CD vs. 12 out of 51 (24%) without CD, p = 0.0006. CONCLUSION It is a non-specific but important finding, as it can have clinical implications.
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Affiliation(s)
- Vikrant Parihar
- Department of Gastroenterology AMNCH, Trinity College Dublin, Dublin, Ireland
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Du L, Shen J, Kim JJ, He H, Chen B, Dai N. Impact of gluten consumption in patients with functional dyspepsia: A case-control study. J Gastroenterol Hepatol 2018; 33:128-133. [PMID: 28452428 DOI: 10.1111/jgh.13813] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/13/2017] [Accepted: 04/25/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Dietary factors and immune dysfunction may induce symptoms in patients with functional dyspepsia (FD). The aim of the study was to evaluate whether gluten consumption impacts symptom onset in patients with FD and to evaluate for possible histologic alterations in the duodenum of patients with FD. METHODS We prospectively enrolled 101 patients newly diagnosed with FD and 31 asymptomatic controls. Specific FD symptoms and gluten consumption patterns were evaluated by self-reported questionnaires. Tight junction protein (claudin-1) expression and presence of intraepithelial lymphocyte (IEL) infiltration in the bulb (D1) and second portion (D2) of the duodenum were assessed by immunohistochemistry. RESULTS Wheat bun consumption had higher frequency (P = 0.047) and increased average consumption (P = 0.01) scores in patients with FD compared with the control group. Of the 101 patients with FD, early satiety (P = 0.03) was associated with increased wheat bun consumption frequency score. On histologic evaluation, claudin-1 expression was decreased in D1 (0.003 ± 0.001 vs 0.012 ± 0.002, P = 0.003) and D2 (0.002 ± 0.0004 vs 0.012 ± 0.001, P < 0.001), while duodenal IEL counts were increased in D1 (15.5 ± 7.8 vs 3.1 ± 2.5, P < 0.001) and D2 (20.6 ± 7.7 vs 5.8 ± 3.4, P < 0.001) among patients with FD compared with the control group. Finally, Helicobacter pylori infection was associated with increased IELs in D1 (20.6 ± 7.0 vs 14.2 ± 7.4, P = 0.001) among patients with FD. CONCLUSIONS Among patients with FD, gluten-rich food may lead to symptom onset, specifically early satiety. Intestinal epithelial barrier dysfunction characterized by decreased claudin-1 expression and mucosal immune activation demonstrated by IEL infiltration may contribute to the pathogenesis of FD.
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Affiliation(s)
- Lijun Du
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jinhua Shen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Department of Gastroenterology, Affiliated Hospital of Shaoxing University, Shaoxing, Zhejiang, China
| | - John J Kim
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Huiqin He
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Binrui Chen
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ning Dai
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Abstract
Celiac disease features duodenal intraepithelial lymphocytosis with or without villous atrophy. Lymphocytosis without villous atrophy will be proven to represent celiac disease in 10% to 20% of cases. The differential diagnosis is broad: Helicobacter pylori gastritis, NSAID injury and bacterial overgrowth are considerations. Lymphocytosis with villous atrophy is very likely to be celiac disease, but there are mimics to consider, including collagenous sprue, tropical sprue, drug injury, and common variable immunodeficiency. Histologic clues to a diagnosis other than celiac disease include paucity of plasma cells, excess of neutrophils, granulomas, and relative paucity of intraepithelial lymphocytes.
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Affiliation(s)
- Thomas C Smyrk
- Department of Pathology, Mayo Clinic, Hilton 11, 200 First Street Southwest, Rochester, MN 55902, USA.
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23
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Vaquero L, Rodríguez-Martín L, Alvarez-Cuenllas B, Hernando M, Iglesias-Blazquez C, Menéndez-Arias C, Vivas S. Coeliac disease and gastrointestinal symptom screening in adult first-degree relatives. J Gastroenterol Hepatol 2017; 32:1931-1937. [PMID: 28387454 DOI: 10.1111/jgh.13801] [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] [Received: 10/24/2016] [Revised: 03/03/2017] [Accepted: 04/06/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM The first-degree relatives (FDRs) of patients with coeliac disease are the main risk group for disease development. The study aims to evaluate the screening strategy in FDRs with negative coeliac serology based on human leukocyte antigen (HLA) genotyping, followed by duodenal biopsy, and to analyze the prevalence of gastrointestinal symptoms and the influence of gluten intake. METHODS Adult FDRs with negative coeliac serology were invited to participate (n = 205), and a total of 139 completed the study protocol. HLA genotyping, transglutaminase antibody assessment, and duodenal biopsy were performed. Symptomatology was assessed using questionnaires during the various phases of dietary modification (baseline diet, gluten-free diet, and gluten overload). RESULTS The study included 139 participants (mean age, 42 years; 53.2% women). HLA-DQ2/8 was positive in 78.4% of the participants (homozygous, 15.1%; heterozygous, 63.3%). Histopathological alterations were noted in 37.1% of participants who underwent duodenal biopsy (Marsh I, 32.7%; Marsh IIIa, 4.4%). At baseline, symptoms were observed in 45.7% of the participants, and the proportion decreased to 24.5% after the gluten-free diet (P < 0.001). Symptoms were not associated with the presence of histological alterations or genetic risk. However, younger age (odds ratio [OR] = 0.91), female sex (OR = 2.9), and the presence of autoimmune disorders (OR = 2.8) were independently associated with a significant symptom response to the gluten-free diet. CONCLUSIONS Duodenal lymphocytosis and atrophy are frequently noted in FDRs, despite negative serological markers. In addition, gastrointestinal symptoms are commonly present and associated with gluten intake regardless of the histological pathology.
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Affiliation(s)
- Luis Vaquero
- Department of Gastroenterology, Department of Biomedical Sciences, University of León, León, Spain
| | - Laura Rodríguez-Martín
- Department of Gastroenterology, Department of Biomedical Sciences, University of León, León, Spain
| | - Begoña Alvarez-Cuenllas
- Department of Gastroenterology, Department of Biomedical Sciences, University of León, León, Spain
| | | | | | | | - Santiago Vivas
- Department of Gastroenterology, Department of Biomedical Sciences, University of León, León, Spain
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24
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Galli G, Purchiaroni F, Lahner E, Sacchi MC, Pilozzi E, Corleto VD, Di Giulio E, Annibale B. Time trend occurrence of duodenal intraepithelial lymphocytosis and celiac disease in an open access endoscopic population. United European Gastroenterol J 2017; 5:811-818. [PMID: 29026595 PMCID: PMC5625866 DOI: 10.1177/2050640616680971] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/30/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Duodenal intraepithelial lymphocytosis (DIL) is a histological finding characterized by the increase of intraepithelial CD3T-lymphocytes over the normal value without villous atrophy, mostly associated to coeliac disease (CD), Helicobacter pylori (Hp) gastritis and autoimmune diseases. OBJECTIVE To assess the occurrence of DIL, CD and Hp gastritis in an endoscopic population over a 13 year period. METHODS From 2003 to 2015 we included adult patients who consecutively underwent oesophago-gastro-duodenoscopy (OGD) with duodenal biopsies assessing the overall and annual occurrence of DIL and CD and the prevalence of Hp gastritis. RESULTS 160 (2.3%) patients with DIL and 275 (3.9%) with CD were detected among 7001 patients. CD occurrence was higher from 2003 to 2011, while since 2012 DIL occurrence gradually increased significantly compared to CD (p = 0.03). DIL patients were more frequently female (p = 0.0006) and underwent OGD more frequently for dyspepsia (p = 0.002) and for indications not related to gastrointestinal symptoms than CD patients (p = 0.0003). Hp gastritis occurred similarly in CD and DIL patients but the latter had higher frequency of atrophic body gastritis (p = 0.005). CONCLUSIONS DIL is a condition increasing in the general endoscopic population mainly diagnosed by chance. Concomitant gastric histological evaluation is able in one third of DIL patients to identify associated possible causes of DIL, such as Hp and atrophic gastritis.
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Affiliation(s)
- Gloria Galli
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, School of Medicine, University Sapienza, Rome, Italy
| | - Flaminia Purchiaroni
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, School of Medicine, University Sapienza, Rome, Italy
| | - Edith Lahner
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, School of Medicine, University Sapienza, Rome, Italy
| | - Maria Carlotta Sacchi
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, School of Medicine, University Sapienza, Rome, Italy
| | - Emanuela Pilozzi
- Clinical Molecular Medicine Department, Sant’Andrea Hospital, School of Medicine, University Sapienza, Rome, Italy
| | - Vito Domenico Corleto
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, School of Medicine, University Sapienza, Rome, Italy
| | - Emilio Di Giulio
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, School of Medicine, University Sapienza, Rome, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant’Andrea Hospital, School of Medicine, University Sapienza, Rome, Italy
- Bruno Annibale, Dipartimento Medico-Chirurgico e Medicina Traslazionale, University Sapienza, Sant’Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy.
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25
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Walker MM, Ludvigsson JF, Sanders DS. Coeliac disease: review of diagnosis and management. Med J Aust 2017; 207:173-178. [PMID: 28814219 DOI: 10.5694/mja16.00788] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 05/26/2017] [Indexed: 12/12/2022]
Abstract
Coeliac disease is an immune-mediated systemic disease triggered by exposure to gluten, and manifested by small intestinal enteropathy and gastrointestinal and extra-intestinal symptoms. Recent guidelines recommend a concerted use of clear definitions of the disease. In Australia, the most recent estimated prevalence is 1.2% in adult men (1:86) and 1.9% in adult women (1:52). Active case finding is appropriate to diagnose coeliac disease in high risk groups. Diagnosis of coeliac disease is important to prevent nutritional deficiency and long term risk of gastrointestinal malignancy. The diagnosis of coeliac disease depends on clinico-pathological correlation: history, presence of antitransglutaminase antibodies, and characteristic histological features on duodenal biopsy (when the patient is on a gluten-containing diet). Human leucocyte antigen class II haplotypes DQ2 or DQ8 are found in nearly all patients with coeliac disease, but are highly prevalent in the general population at large (56% in Australia) and testing can only exclude coeliac disease for individuals with non-permissive haplotypes. Adhering to a gluten free diet allows duodenal mucosal healing and alleviates symptoms. Patients should be followed up with a yearly review of dietary adherence and a health check. Non-coeliac gluten or wheat protein sensitivity is a syndrome characterised by both gastrointestinal and extra-intestinal symptoms related to the ingestion of gluten and possibly other wheat proteins in people who do not have coeliac disease or wheat allergy recognised by diagnostic tests.
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26
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Clinical and Histologic Mimickers of Celiac Disease. Clin Transl Gastroenterol 2017; 8:e114. [PMID: 28817113 PMCID: PMC5587842 DOI: 10.1038/ctg.2017.41] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 07/02/2017] [Indexed: 02/07/2023] Open
Abstract
Celiac disease is an autoimmune disorder of the small bowel, classically associated with diarrhea, abdominal pain, and malabsorption. The diagnosis of celiac disease is made when there are compatible clinical features, supportive serologic markers, representative histology from the small bowel, and response to a gluten-free diet. Histologic findings associated with celiac disease include intraepithelial lymphocytosis, crypt hyperplasia, villous atrophy, and a chronic inflammatory cell infiltrate in the lamina propria. It is important to recognize and diagnose celiac disease, as strict adherence to a gluten-free diet can lead to resolution of clinical and histologic manifestations of the disease. However, many other entities can present with clinical and/or histologic features of celiac disease. In this review article, we highlight key clinical and histologic mimickers of celiac disease. The evaluation of a patient with serologically negative enteropathy necessitates a carefully elicited history and detailed review by a pathologist. Medications can mimic celiac disease and should be considered in all patients with a serologically negative enteropathy. Many mimickers of celiac disease have clues to the underlying diagnosis, and many have a targeted therapy. It is necessary to provide patients with a correct diagnosis rather than subject them to a lifetime of an unnecessary gluten-free diet.
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27
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Bhakta D, Hair C, Green L, Duong N, Thrift AP, Kramer JR, El-Serag HB. Prevalence of Celiac Disease Among Unsuspected Patients Presenting to Open Access Endoscopy. Clin Gastroenterol Hepatol 2017; 15:137-139. [PMID: 27567695 DOI: 10.1016/j.cgh.2016.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/11/2016] [Accepted: 08/15/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Dimpal Bhakta
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Clark Hair
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Linda Green
- Department of Pathology, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Ngoc Duong
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Aaron P Thrift
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Jennifer R Kramer
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
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28
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Ierardi E, Losurdo G, Iannone A, Piscitelli D, Amoruso A, Barone M, Principi M, Pisani A, Di Leo A. Lymphocytic duodenitis or microscopic enteritis and gluten-related conditions: what needs to be explored? Ann Gastroenterol 2017; 30:380-392. [PMID: 28655974 PMCID: PMC5479990 DOI: 10.20524/aog.2017.0165] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/10/2017] [Indexed: 02/07/2023] Open
Abstract
Microscopic enteritis (ME) is characterized by abnormal infiltration of intraepithelial lymphocytes in intestinal mucosa. It was described as duodenal lymphocytosis or lymphocytic duodenitis until the dedicated Consensus Conference of 2015. ME represents a common feature of several gluten-mediated and non-gluten related diseases; therefore, it is an umbrella term embracing several conditions. The most frequent causes of ME are gluten-related disorders (celiac disease, non-celiac gluten sensitivity, wheat allergy), Helicobacter pylori infection and drug-related damages. Less frequently, ME may be secondary to inflammatory bowel disease, some autoimmune conditions, immunoglobulin deficiencies, blood malignancies, infections and irritable bowel syndrome. Therefore, the differential diagnosis of ME may be challenging. The diagnosis of ME needs to be driven by predominant symptoms and patient history. However, it is often difficult to achieve an immediate identification of the underlying condition, and a broad variety of diagnostic tests may be required. Ultimately, long-term surveillance is needed for a final diagnosis in many cases, since a hidden or quiescent condition may be disclosed after a period of latency. In any case, strict collaboration between the clinician and the pathologist is pivotal. The treatment of ME should be personalized, depending on the underlying disease. For gluten-related conditions (celiac disease, gluten sensitivity, wheat allergy, dermatitis herpetiformis), a gluten-free diet may be proposed. For other conditions, a targeted etiologic treatment is necessary. In conclusion, ME represents a novel entity that is attracting increasing interest. The growing epidemiologic trend confirms that it will become a common condition in clinical practice.
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Affiliation(s)
- Enzo Ierardi
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
- Correspondence to: Prof. Enzo Ierardi, Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, Piazza Giulio Cesare, Bari, University of Bari, Italy, Tel.: +39 080 5594033, Fax: +39 080 5593088, e-mail:
| | - Giuseppe Losurdo
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Andrea Iannone
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Domenico Piscitelli
- Section of Pathology (Domenico Piscitelli), Department of Emergency and Organ Transplantation, AOU Policlinico, Piazza Giulio Cesare, Bari, University of Bari, Italy
| | - Annacinzia Amoruso
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Michele Barone
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Mariabeatrice Principi
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Antonio Pisani
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
| | - Alfredo Di Leo
- Section of Gastroenterology (Enzo Ierardi, Giuseppe Losurdo, Andrea Iannone, Annacinzia Amoruso, Michele Barone, Mariabeatrice Principi, Antonio Pisani, Alfredo Di Leo)
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Hære P, Høie O, Schulz T, Schönhardt I, Raki M, Lundin KEA. Long-term mucosal recovery and healing in celiac disease is the rule - not the exception. Scand J Gastroenterol 2016; 51:1439-1446. [PMID: 27534885 DOI: 10.1080/00365521.2016.1218540] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The prevalence of persistent villous atrophy (VA) in patients with celiac disease (CD) on a gluten-free diet (GFD) varies greatly between studies. Most studies show a relatively high prevalence of mucosal atrophy and inflammation in treated patients, a finding which have led to a concept of non-responsive CD. Few studies have examined the prevalence of long-term mucosal healing. Our study aimed to determine the extent of mucosal healing in a cohort of Norwegian patients with CD treated with GFD for several years. MATERIALS AND METHODS Adult patients diagnosed with VA between 1989 and 2009 were included. We performed a follow-up gastroscopy with duodenal biopsies. Two pathologists evaluated the biopsies according to the Marsh-Oberhuber classification. Mucosal healing was defined as Marsh 0 while mucosal recovery was defined as Marsh 0-2. RESULTS Duodenal biopsies were obtained from 127 adult patients with established CD. After a follow-up time of 8.1 years (median, range 2.3-22.3), 103 (81%) of the patients showed mucosal healing, 120 patients (94%) showed mucosal recovery, and 7 patients (6%) showed persistent VA. In addition, 103 of the 127 patients (81%) had undergone a routine follow-up biopsy 12.6 months (median, range 5.2-28.8) after diagnosis. At the time of the routine follow-up, only 52 of these patients (50.5%) had achieved mucosal recovery. CONCLUSIONS Although half of the patients had persistent VA at the time of routine follow-up, both long-term mucosal recovery and healing is possible for the vast majority of adult patients with CD.
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Affiliation(s)
- Petter Hære
- a Department of Gastroenterology , Sørlandet Hospital HF , Arendal , Norway
| | - Ole Høie
- a Department of Gastroenterology , Sørlandet Hospital HF , Arendal , Norway
| | - Tom Schulz
- a Department of Gastroenterology , Sørlandet Hospital HF , Arendal , Norway
| | - Irina Schönhardt
- b Department of Pathology , Sørlandet Hospital HF , Kristiansand , Norway
| | - Melinda Raki
- c Department of Pathology , Oslo University Hospital , Oslo , Norway
| | - Knut E A Lundin
- d CIR - Centre for Immune Regulation in Oslo, Oslo University Hospital, University of Oslo , Oslo , Norway
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30
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Bonagura GA, Ribaldone DG, Fagoonee S, Sapone N, Caviglia GP, Saracco GM, Astegiano M, Pellicano R. Microscopic colitis in patients with mild duodenal damage: A new clinical and pathological entity (“lymphocytic enterocolitis”)? World J Gastrointest Pathophysiol 2016; 7:307-313. [PMID: 27895976 PMCID: PMC5108976 DOI: 10.4291/wjgp.v7.i4.307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/03/2016] [Accepted: 09/22/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the potential association between mild duodenal damage and microscopic colitis (MC).
METHODS We retrospectively included 105 consecutive patients with type I Marsh-Oberhuber duodenal damage and negativity for immunoglobulin A anti-endomysium and anti-tissue transglutaminase. The following parameters were analyzed: Sex, age at execution of esophagogastroduodenoscopy, duodenal damage, and number of intraepithelial lymphocytes at biopsies, prevalence of Helicobacter pylori infection, age at execution of colonoscopy, macroscopic and microscopic features of colonoscopy, family history of gastrointestinal and autoimmune diseases, smoking habits, biochemical parameters of inflammation and autoimmunity, use of proton pump inhibitors or nonsteroidal anti-inflammatory drugs, adverse reactions to drugs or foods, pathologies known to be associated with celiac disease or MC, living on a gluten-free diet or on a gluten-low diet for at least 1 mo.
RESULTS Colonoscopy was performed in 59 patients, but only in 48 of them biopsies were taken in the entire colon. Considering the latter cohort, the diagnosis of MC was met in 25 (52.1%) patients while in 18 patients other pathologic findings were reported: 13 (27%) cases of nonspecific inflammatory bowel disease, 2 (4.2%) cases of Crohn’s disease, 2 (4.2%) cases of eosinophilic gastroenteritis, and 1 (2.1%) case of autoimmune enteritis. Five (10.4%) patients had a normal colonoscopic result. Matching the groups by age, and considering only patients who underwent colonoscopy (42.7 ± 15.5 years) vs those who did not undergo colonoscopy (36.9 ± 10.6 years), a statistical difference was found (P = 0.039). Focusing on symptoms, diarrhea was statistically more prevalent in MC group than in patients who did not undergo colonoscopy (P = 0.03).
CONCLUSION Mild duodenal damage is associated with MC in more than half of the cases. This association supports the hypothesis of a link between these two entities.
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Zanini B, Marullo M, Villanacci V, Salemme M, Lanzarotto F, Ricci C, Lanzini A. Persistent Intraepithelial Lymphocytosis in Celiac Patients Adhering to Gluten-Free Diet Is Not Abolished Despite a Gluten Contamination Elimination Diet. Nutrients 2016; 8:nu8090525. [PMID: 27571100 PMCID: PMC5037512 DOI: 10.3390/nu8090525] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/04/2016] [Accepted: 08/16/2016] [Indexed: 02/06/2023] Open
Abstract
The gluten-free diet (GFD) is the only validated treatment for celiac disease (CD), but despite strict adherence, complete mucosal recovery is rarely obtained. The aim of our study was to assess whether complete restitutio ad integrum could be achieved by adopting a restrictive diet (Gluten Contamination Elimination Diet, GCED) or may depend on time of exposure to GFD. Two cohorts of CD patients, with persisting Marsh II/Grade A lesion at duodenal biopsy after 12–18 months of GFD (early control) were identified. Patients in Cohort A were re-biopsied after a three-month GCED (GCED control) and patients in Cohort B were re-biopsied after a minimum of two years on a standard GFD subsequent to early control (late control). Ten patients in Cohort A and 19 in Cohort B completed the study protocol. There was no change in the classification of duodenal biopsies in both cohorts. The number of intraepithelial lymphocytes, TCRγδ+ (T-Cell Receptor gamma delta) T cell and eosinophils significantly decreased at GCED control (Cohort A) and at late control (Cohort B), compared to early control. Duodenal intraepithelial lymphocytosis persisting in CD patients during GFD is not eliminated by a GCED and is independent of the length of GFD. [NCT 02711696]
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Affiliation(s)
- Barbara Zanini
- Gastroenterology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Monica Marullo
- Gastroenterology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Vincenzo Villanacci
- Histopathology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Marianna Salemme
- Histopathology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Francesco Lanzarotto
- Gastroenterology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Chiara Ricci
- Gastroenterology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
| | - Alberto Lanzini
- Gastroenterology Unit, University and Spedali Civili of Brescia, Piazzale Spedali Civili, Brescia I-25123, Italy.
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Double-Blind Randomized Clinical Trial: Gluten versus Placebo Rechallenge in Patients with Lymphocytic Enteritis and Suspected Celiac Disease. PLoS One 2016; 11:e0157879. [PMID: 27392045 PMCID: PMC4938236 DOI: 10.1371/journal.pone.0157879] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/03/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The role of gluten as a trigger of symptoms in non-coeliac gluten sensitivity has been questioned. AIM To demonstrate that gluten is the trigger of symptoms in a subgroup of patients fulfilling the diagnostic criteria for non-coeliac gluten sensitivity (NCGS), which presented with lymphocytic enteritis, positive celiac genetics and negative celiac serology. METHODS Double-blind randomized clinical trial of gluten vs placebo rechallenge. INCLUSION CRITERIA >18 years of age, HLA-DQ2/8+, negative coeliac serology and gluten-dependent lymphocytic enteritis, and GI symptoms, with clinical and histological remission at inclusion. Eighteen patients were randomised: 11 gluten (20 g/day) and 7 placebo. Clinical symptoms, quality of life (GIQLI), and presence of gamma/delta+ cells and transglutaminase deposits were evaluated. RESULTS 91% of patients had clinical relapse during gluten challenge versus 28.5% after placebo (p = 0.01). Clinical scores and GIQLI worsened after gluten but not after placebo (p<0.01). The presence of coeliac tissue markers at baseline biopsy on a gluten-free diet allowed classifying 9 out of the 18 (50%) patients as having probable 'coeliac lite' disease. CONCLUSION This proof-of-concept study indicates that gluten is the trigger of symptoms in a subgroup of patients fulfilling the diagnostic criteria for NCGS. They were characterized by positive celiac genetics, lymphocytic enteritis, and clinical and histological remission after a gluten-free diet. TRIAL REGISTRATION ClinicalTrials.gov NCT02472704.
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Mooney PD, Kurien M, Evans KE, Rosario E, Cross SS, Vergani P, Hadjivassiliou M, Murray JA, Sanders DS. Clinical and Immunologic Features of Ultra-Short Celiac Disease. Gastroenterology 2016; 150:1125-1134. [PMID: 26836585 DOI: 10.1053/j.gastro.2016.01.029] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 01/12/2016] [Accepted: 01/25/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS The clinical effects of gluten-sensitive enteropathy with villous atrophy limited to the duodenal bulb (D1) have not been delineated in adults with celiac disease. We investigated the sensitivity of D1 biopsy analysis in the detection of celiac disease, the number and sites of biopsies required to detect ultra-short celiac disease (USCD, villous atrophy limited to D1), and the clinical phenotype of USCD. METHODS We performed a prospective study of 1378 patients (mean age, 50.3 y; 62% female) who underwent endoscopy at a tertiary medical center in the United Kingdom from 2008 through 2014; routine duodenal biopsy specimens were collected from D1 and the second part of the duodenum (D2). Quadrantic D1 biopsy specimens were collected from 171 consecutive patients with a high suspicion of celiac disease (mean age, 46.5 y; 64% female). Clinical data from patients diagnosed with USCD, based on biopsy analysis, were compared with those from patients with conventional celiac disease (CCD) (villous atrophy beyond D1) and individuals without celiac disease (controls). The number of intraepithelial lymphocytes (IELs) and immune phenotypes were compared between D1 vs D2 in patients with celiac disease. RESULTS Of the 1378 patients assessed, 268 (19.4%) were diagnosed with celiac disease; 9.7% of these patients had villous atrophy confined to D1 (USCD; P < .0001). Collection of a single additional biopsy specimen from any D1 site increased the sensitivity of celiac disease detection by 9.3%-10.8% (P < .0001). Patients with USCD were younger (P = .03), had lower titers of tissue transglutaminase antibody (P = .001), and less frequently presented with diarrhea (P = .001) than patients with CCD. Higher proportions of patients with CCD had ferritin deficiency (P = .007) or folate deficiency (P = .003) than patients with USCD or controls. Patients with celiac disease had a median of 50 IELs/100 enterocytes in D1 and a median of 48 IELs/100 enterocytes (P = .7) in D2. The phenotype of IELs from patients with D1 celiac disease was indistinguishable from those of patients with D2 celiac disease. CONCLUSIONS Collection of a single additional biopsy specimen from any site in the D1 intestine increases the sensitivity of detection for celiac disease. Patients with USCD may have early stage or limited celiac disease, with a mild clinical phenotype and infrequent nutritional deficiencies.
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Affiliation(s)
- Peter D Mooney
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom; University of Sheffield, Sheffield, United Kingdom.
| | - Matthew Kurien
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom; University of Sheffield, Sheffield, United Kingdom
| | - Kate E Evans
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom; University of Sheffield, Sheffield, United Kingdom
| | | | - Simon S Cross
- University of Sheffield, Sheffield, United Kingdom; Department of Histopathology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Patricia Vergani
- Department of Histopathology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Marios Hadjivassiliou
- University of Sheffield, Sheffield, United Kingdom; Department of Neurology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | | | - David S Sanders
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom; University of Sheffield, Sheffield, United Kingdom
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Frequency and Cause of Persistent Symptoms in Celiac Disease Patients on a Long-term Gluten-free Diet. J Clin Gastroenterol 2016; 50:239-43. [PMID: 26280705 DOI: 10.1097/mcg.0000000000000392] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOALS To estimate the frequency and cause of nonresponsive celiac disease (CD). BACKGROUND Treatment of CD is based on life-long adherence to a gluten-free diet (GFD). Some celiac patients experience persistence of symptoms despite a GFD. This condition is defined as nonresponsive CD. STUDY Celiac patients on a GFD for at least 12 months underwent diet compliance assessment, laboratory tests, breath tests, endoscopic, and histologic evaluations according to the symptoms/signs reported. RESULTS Seventy of 321 (21.8%) patients had persistent or recurrent symptoms/signs. The cause of symptom persistence was evaluated in 56 of 70 patients. Thirteen of 56 (23%) patients were antiendomysial antibody positive. Among the patients with negative serology, 1 had fibromyalgia, and 3 had evidence that disproved the diagnosis of CD. The remaining 39 patients with negative serology underwent duodenal biopsy sampling, which evidenced histologic alterations in 24 patients. Among the 15 patients with normal histology 3 were lactose intolerant, 9 had irritable bowel syndrome, 2 had gastroesophageal reflux disease, and in 1 patient a cause for the persistent symptom was not identified. In patients with confirmed diagnosis of CD, exposure to dietary gluten was the main cause of persistence of symptoms/signs, and consistently after dietary modification, symptoms resolved in 63% of the patients at later time points during follow-up. CONCLUSION Nonresponsive CD occurs in nearly one fifth of celiac patients on GFD and its occurrence suggests further investigations to optimize the management of celiac patients.
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Abstract
The past 5 years have seen an increase in the use of a gluten-free diet outside a diagnosis of coeliac disease or IgE-mediated wheat allergy. This trend has led to the identification of a new clinical entity termed noncoeliac gluten sensitivity (NCGS). In this Review, we discuss the evidence for NCGS as demonstrated by the results of double-blind, placebo-controlled dietary rechallenge studies. Furthermore, the characteristic phenotype of individuals with NCGS is described as well as the symptom manifestations commonly reported after gluten exposure, which include intestinal symptoms consistent with IBS, and extraintestinal symptoms such as neurological dysfunction, psychological disturbances, fibromyalgia and skin rash. Moreover, emerging evidence suggests that NCGS can be associated with organic gastrointestinal pathologies, such as IBD, in which its presence might be a reflection of severe or stricturing disease. However, NCGS is not without its controversies and uncertainties, in particular pertaining to whether it is gluten or nongluten components of the grain evoking symptoms; evidence suggests that fermentable carbohydrates, amylase trypsin inhibitors and wheat-germ agglutinin can also be responsible culprits. Finally, we discuss the novel techniques that might help diagnose NCGS in the future.
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Affiliation(s)
- Imran Aziz
- Department of Gastroenterology, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
| | - Marios Hadjivassiliou
- Department of Neurosciences, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
| | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
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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: 1.7] [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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Elli L, Branchi F, Tomba C, Villalta D, Norsa L, Ferretti F, Roncoroni L, Bardella MT. Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity. World J Gastroenterol 2015; 21:7110-7119. [PMID: 26109797 PMCID: PMC4476872 DOI: 10.3748/wjg.v21.i23.7110] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 04/03/2015] [Accepted: 05/04/2015] [Indexed: 02/06/2023] Open
Abstract
Cereal crops and cereal consumption have had a vital role in Mankind’s history. In the recent years gluten ingestion has been linked with a range of clinical disorders. Gluten-related disorders have gradually emerged as an epidemiologically relevant phenomenon with an estimated global prevalence around 5%. Celiac disease, wheat allergy and non-celiac gluten sensitivity represent different gluten-related disorders. Similar clinical manifestations can be observed in these disorders, yet there are peculiar pathogenetic pathways involved in their development. Celiac disease and wheat allergy have been extensively studied, while non-celiac gluten sensitivity is a relatively novel clinical entity, believed to be closely related to other gastrointestinal functional syndromes. The diagnosis of celiac disease and wheat allergy is based on a combination of findings from the patient’s clinical history and specific tests, including serology and duodenal biopsies in case of celiac disease, or laboratory and functional assays for wheat allergy. On the other hand, non-celiac gluten sensitivity is still mainly a diagnosis of exclusion, in the absence of clear-cut diagnostic criteria. A multimodal pragmatic approach combining findings from the clinical history, symptoms, serological and histological tests is required in order to reach an accurate diagnosis. A thorough knowledge of the differences and overlap in clinical presentation among gluten-related disorders, and between them and other gastrointestinal disorders, will help clinicians in the process of differential diagnosis.
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Molina-Infante J, Santolaria S, Sanders DS, Fernández-Bañares F. Systematic review: noncoeliac gluten sensitivity. Aliment Pharmacol Ther 2015; 41:807-20. [PMID: 25753138 DOI: 10.1111/apt.13155] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 01/27/2015] [Accepted: 02/15/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Noncoeliac gluten sensitivity (NCGS) is a controversial emerging disorder. Despite reported symptoms related to the ingestion of gluten, NCGS remains a diagnosis based on the exclusion of coeliac disease, given the absence of reliable biomarkers. AIM To evaluate the prevalence, diagnostic exclusion of coeliac disease and the efficacy of a gluten-free diet (GFD) for NCGS patients. METHODS A PubMed search was performed up to December 2014. According to consensus diagnostic criteria, NCGS was defined as self-reported gluten intolerance, negative coeliac serology and absence of villous atrophy. Studies evaluating the impact of a GFD on patients with irritable bowel syndrome (IBS) were also included. RESULTS Prevalence rates of NCGS (0.5-13%) differed widely. Seventeen studies, including 1561 patients (26 children), met the inclusion criteria for NCGS. HLA haplotypes could not be linked to histology [normal or lymphocytic enteritis (LE)] in 1123 NCGS patients. HLADQ2/DQ8 haplotypes were present in 44% of NCGS patients. After advanced diagnostic techniques in 189 NCGS patients combining LE and HLADQ2/DQ8 haplotypes, 39 (20%) were reclassified as coeliac disease. There was a higher than expected family history of coeliac disease and autoimmune disorders in NCGS patients. A GFD resulted in variable results for variable, but significantly improved stool frequency in HLADQ2 positive diarrhoea-predominant IBS patients. CONCLUSIONS Prevalence rates for NCGS are extremely variable. A subset of NCGS patients might belong in the so-called 'coeliac-lite' disease. The benefit of a GFD for NCGS patients is currently controversial. HLADQ2 positive diarrhoea-type IBS patients might gain symptom improvement from a GFD.
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Affiliation(s)
- J Molina-Infante
- Department of Gastroenterology, Hospital San Pedro de Alcantara, Caceres, Spain
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Discriminant score for celiac disease based on immunohistochemical analysis of duodenal biopsies. J Pediatr Gastroenterol Nutr 2015; 60:621-5. [PMID: 25514620 DOI: 10.1097/mpg.0000000000000675] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Celiac disease (CD) represents a spectrum, which includes cases with minor histological abnormalities (potential CD). The aim of this work is to evaluate the contribution of immunohistochemical analysis of duodenal biopsies to the diagnosis of gluten-related minor enteropathy. METHODS Duodenal biopsies from 56 patients with untreated CD and 56 controls were analyzed for CD3 and γδ intraepithelial lymphocyte number, γδ/CD3 ratio, and density of CD25+ lamina propria cells. A discriminant equation was obtained by which 61 more biopsies with normal villous architecture were blindly evaluated. RESULTS All of the immunohistochemical parameters were significantly different between patients with CD and controls. None of the single parameters showed sufficient specificity for CD. The combination of all of the 4 markers resulted in the following discriminant equation: discriminant score (Dscore) = (CD3 × 0.06) - (γδ × 0.119) + (CD25 × 0.012) + (γδ/CD3 × 0.131) - 4.709. Using this Dscore, patients were correctly classified as celiac or controls in 97.3% of the cases. When this equation was applied to a validation set of 61 patients with normal villous architecture and unknown diagnosis, 92.9% of those with a positive score turned out to be patients with potential CD. A normal score, however, did not exclude this condition. CONCLUSIONS Immunohistochemistry represents a specific tool for the diagnosis of CD, but does lack sensitivity in detecting all of the potential CD cases.
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Rostami K, Aldulaimi D, Holmes G, Johnson MW, Robert M, Srivastava A, Fléjou JF, Sanders DS, Volta U, Derakhshan MH, Going JJ, Becheanu G, Catassi C, Danciu M, Materacki L, Ghafarzadegan K, Ishaq S, Rostami-Nejad M, Peña AS, Bassotti G, Marsh MN, Villanacci V. Microscopic enteritis: Bucharest consensus. World J Gastroenterol 2015; 21:2593-2604. [PMID: 25759526 PMCID: PMC4351208 DOI: 10.3748/wjg.v21.i9.2593] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 12/29/2014] [Accepted: 01/21/2015] [Indexed: 02/06/2023] Open
Abstract
Microscopic enteritis (ME) is an inflammatory condition of the small bowel that leads to gastrointestinal symptoms, nutrient and micronutrient deficiency. It is characterised by microscopic or sub-microscopic abnormalities such as microvillus changes and enterocytic alterations in the absence of definite macroscopic changes using standard modern endoscopy. This work recognises a need to characterize disorders with microscopic and submicroscopic features, currently regarded as functional or non-specific entities, to obtain further understanding of their clinical relevance. The consensus working party reviewed statements about the aetiology, diagnosis and symptoms associated with ME and proposes an algorithm for its investigation and treatment. Following the 5th International Course in Digestive Pathology in Bucharest in November 2012, an international group of 21 interested pathologists and gastroenterologists formed a working party with a view to formulating a consensus statement on ME. A five-step agreement scale (from strong agreement to strong disagreement) was used to score 21 statements, independently. There was strong agreement on all statements about ME histology (95%-100%). Statements concerning diagnosis achieved 85% to 100% agreement. A statement on the management of ME elicited agreement from the lowest rate (60%) up to 100%. The remaining two categories showed general agreement between experts on clinical presentation (75%-95%) and pathogenesis (80%-90%) of ME. There was strong agreement on the histological definition of ME. Weaker agreement on management indicates a need for further investigations, better definitions and clinical trials to produce quality guidelines for management. This ME consensus is a step toward greater recognition of a significant entity affecting symptomatic patients previously labelled as non-specific or functional enteropathy.
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Patterson ER, Shmidt E, Oxentenko AS, Enders FT, Smyrk TC. Normal villous architecture with increased intraepithelial lymphocytes: a duodenal manifestation of Crohn disease. Am J Clin Pathol 2015; 143:445-50. [PMID: 25696804 DOI: 10.1309/ajcpbkqnd4shvx9q] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To assess a possible association between inflammatory bowel disease (IBD) and the histologic finding in duodenal biopsy specimens of increased intraepithelial lymphocytes (IELs) with normal villous architecture. METHODS We identified all patients with duodenal biopsy specimens obtained between 2000 and 2010 showing increased IELs and normal architecture. Among the 74 such patients who also had IBD, we characterized the clinical features of IBD and reviewed all available upper gastrointestinal biopsy specimens. RESULTS Fifty-eight patients had Crohn disease, 13 had ulcerative colitis, and three had IBD, type unclassified. No duodenal sample with increased IELs had other histologic features of IBD. Among gastric biopsy specimens from 34 patients with Crohn disease, nearly half (16) had focal gastritis. CONCLUSIONS We propose that Crohn disease be included in the differential diagnosis for increased IELs with normal villous architecture in duodenal biopsy specimens, particularly when gastric biopsy specimens show focal gastritis.
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Affiliation(s)
| | | | - Amy S Oxentenko
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, and
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Vanheel H, Vanuytsel T, Farré R, Tack J. Authors' response: Impaired duodenal mucosal integrity and low-grade inflammation in functional dyspepsia. Gut 2015; 64:357-8. [PMID: 24763131 DOI: 10.1136/gutjnl-2014-307325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Hanne Vanheel
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Ricard Farré
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
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Abstract
Among the adverse reactions caused by wheat, celiac disease (CD) is the longest studied and best-known pathology. The more recently defined non-celiac gluten sensitivity (NCGS) presents with symptoms which are often indistinguishable from CD. Diagnosis of CD is based on serologic, molecular, and bioptic testing. The IgA anti-transglutaminase (tTG) test is considered highly important, as it shows high sensitivity and specificity and its levels correlate to the degree of intestinal damage. Small bowel biopsy can be avoided in symptomatic patients with IgA anti-tTG levels above 10× the manufacturer's cut-off. Recently, tests of anti-deamidated peptides of gliadin (DGP) have replaced classic anti-native gliadin (AGA) tests. DGP assays have a considerably higher diagnostic accuracy than AGA assays, especially in the IgG class, and can replace anti-tTG tests in patients with selective IgA deficiency. The combination of IgG anti-DGP plus IgA anti-tTG assays show greater sensitivity than a single test, with very high specificity. EMA tests have great diagnostic accuracy but are not recommended by all the latest guidelines because they are observer dependent. Biopsy must still be considered the gold standard for CD diagnosis. HLA-DQ genotyping can be used to screen asymptomatic children and in cases of histology/serology disagreement. About half of NCGS patients are DQ2 positive and have IgG AGA. To diagnose NCGS, first CD and wheat allergy must be excluded; then the wheat dependence of symptoms must be verified by a gluten-free diet and subsequent gluten challenge.
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Lauwers GY, Fasano A, Brown IS. Duodenal lymphocytosis with no or minimal enteropathy: much ado about nothing? Mod Pathol 2015; 28 Suppl 1:S22-9. [PMID: 25560597 DOI: 10.1038/modpathol.2014.135] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 09/18/2014] [Accepted: 09/18/2014] [Indexed: 02/06/2023]
Abstract
Duodenal lymphocytosis is a nonspecific finding that is being detected with heightened frequency. Although increased intraepithelial lymphocytosis with normal villous architecture classically corresponds to grade 1 of the Marsh classification, many other conditions have been reported to be associated with this histologic pattern. In this article, we offer a broad review of the associations of isolated increased intraepithelial lymphocytosis with celiac and nonceliac gluten sensitivity, as well as of the broadening nonceliac etiologies.
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Affiliation(s)
- Gregory Y Lauwers
- Gastrointestinal Pathology Service, Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Alessio Fasano
- Division of Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Boston, MA, USA
| | - Ian S Brown
- Envoi Pathology, Brisbane, Queensland, Australia
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Rodrigo L, Blanco I, Bobes J, de Serres FJ. Remarkable prevalence of coeliac disease in patients with irritable bowel syndrome plus fibromyalgia in comparison with those with isolated irritable bowel syndrome: a case-finding study. Arthritis Res Ther 2014; 15:R201. [PMID: 24283458 PMCID: PMC3978893 DOI: 10.1186/ar4391] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 11/18/2013] [Indexed: 12/12/2022] Open
Abstract
Introduction Irritable bowel syndrome (IBS) and fibromyalgia syndrome (FMS) are two common central sensitization disorders frequently associated in the same patient, and some of these patients with IBS plus FMS (IBS/FMS) could actually be undiagnosed of coeliac disease (CD). The present study was an active case finding for CD in two IBS cohorts, one constituted by IBS/FMS subjects and the other by people with isolated IBS. Methods A total of 104 patients (89.4% females) fulfilling the 1990 ACR criteria for FMS and the Rome III criteria for IBS classification and 125 unrelated age- and sex-matched IBS patients without FMS underwent the following studies: haematological, coagulation and biochemistry tests, serological and genetic markers for CD (i.e., tissue transglutaminase 2 (tTG-2) and major histocompatibility complex HLA-DQ2/HLA-DQ8), multiple gastric and duodenal biopsies, FMS tender points (TPs), Fibromyalgia Impact Questionnaire (FIQ), Health Assessment Questionnaire (HAQ), 36-Item Short Form Health Survey (SF-36) and Visual Analogue Scales (VASs) for tiredness and gastrointestinal complaints. Results As a whole, IBS/FMS patients scored much worse in quality of life and VAS scores than those with isolated IBS (P < 0.001). Seven subjects (6.7%) from the IBS/FMS group displayed HLA-DQ2/HLA-DQ8 positivity, high tTG-2 serum levels and duodenal villous atrophy, concordant with CD. Interestingly enough, these seven patients were started on a gluten-free diet (GFD), showing a remarkable improvement in their digestive and systemic symptoms on follow-up. Conclusions The findings of this screening indicate that a non-negligible percentage of IBS/FMS patients are CD patients, whose symptoms can improve and in whom long-term CD-related complications might possibly be prevented with a strict lifelong GFD.
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Aziz I, Hadjivassiliou M, Sanders DS. Self-reported gluten sensitivity: an international concept in need of consensus? Am J Gastroenterol 2014; 109:1498-9. [PMID: 25196880 DOI: 10.1038/ajg.2014.205] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Imran Aziz
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | | | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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Rodrigo L, Blanco I, Bobes J, de Serres FJ. Effect of one year of a gluten-free diet on the clinical evolution of irritable bowel syndrome plus fibromyalgia in patients with associated lymphocytic enteritis: a case-control study. Arthritis Res Ther 2014; 16:421. [PMID: 25160886 PMCID: PMC4177310 DOI: 10.1186/s13075-014-0421-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 08/08/2014] [Indexed: 12/11/2022] Open
Abstract
Introduction Irritable bowel syndrome (IBS), lymphocytic enteritis (LE) and fibromyalgia syndrome (FMS) are three common disorders. Since a gluten-free diet (GFD) has been shown to be helpful in LE, we aimed to assess its effect in a series of LE patients also diagnosed with IBS and FMS. Methods The study sample comprised 97 IBS plus FMS adult females, of whom 58 had LE (Marsh stage 1), and 39 had a normal duodenal biopsy (Marsh stage 0). All patients fulfilled the Rome III and American College of Rheumatology 1990 criteria. All participants followed a GFD, the effectiveness of which was assessed by changes in the results of several tests, including those of the Fibromyalgia Impact Questionnaire (FIQ), the Health Assessment Questionnaire (HAQ), tender points (TPs), the Short Form Health Survey (SF-36), and the Visual Analogue Scales (VAS) for gastrointestinal complaints, pain and fatigue. Results At baseline, all patients had a poor quality of life (QoL) and high VAS scores. After one year on a GFD, all outcome measures were somewhat better in the Marsh stage 1 group, with a mean decrease of 26 to 29% in the TPs, FIQ, HAQ and VAS scales, accompanied by an increase of 27% in the SF-36 physical and mental component scores. However, in the IBS plus FMS/Marsh stage 0 group, the GFD had almost no effect. Conclusions This pilot study shows that a GFD in the LE-related IBS/FMS subgroup of patients can produce a slight but significant improvement in all symptoms. Our findings suggest that further studies of this subject are warranted.
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Ludvigsson JF, Bai JC, Biagi F, Card TR, Ciacci C, Ciclitira PJ, Green PHR, Hadjivassiliou M, Holdoway A, van Heel DA, Kaukinen K, Leffler DA, Leonard JN, Lundin KEA, McGough N, Davidson M, Murray JA, Swift GL, Walker MM, Zingone F, Sanders DS. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut 2014; 63:1210-28. [PMID: 24917550 PMCID: PMC4112432 DOI: 10.1136/gutjnl-2013-306578] [Citation(s) in RCA: 706] [Impact Index Per Article: 70.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A multidisciplinary panel of 18 physicians and 3 non-physicians from eight countries (Sweden, UK, Argentina, Australia, Italy, Finland, Norway and the USA) reviewed the literature on diagnosis and management of adult coeliac disease (CD). This paper presents the recommendations of the British Society of Gastroenterology. Areas of controversies were explored through phone meetings and web surveys. Nine working groups examined the following areas of CD diagnosis and management: classification of CD; genetics and immunology; diagnostics; serology and endoscopy; follow-up; gluten-free diet; refractory CD and malignancies; quality of life; novel treatments; patient support; and screening for CD.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
| | - Julio C Bai
- Department of Medicine, Dr C. Bonorino Udaondo Gastroenterology Hospital, Del Salvador University, Buenos Aires, Argentina
| | - Federico Biagi
- Coeliac Centre/1st Department of Internal Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Timothy R Card
- University of Nottingham, Department of Epidemiology and Public Health, Nottingham City Hospital, Nottingham, UK
| | - Carolina Ciacci
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Paul J Ciclitira
- Gastroenterology, Division of Nutritional Sciences, King's College London, The Rayne Institute, St Thomas Hospital, London, UK
| | - Peter H R Green
- Coeliac Disease Center at Columbia University, New York, New York, USA
| | | | - Anne Holdoway
- Registered dietitian and representative of the British Dietetic Association, Bath, Somerset, UK
| | - David A van Heel
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Katri Kaukinen
- School of Medicine, University of Tampere, Tampere, Finland Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland Department of Medicine, Seinäjoki Central Hospital, Finland
| | - Daniel A Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan N Leonard
- Department of Dermatology, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Knut E A Lundin
- Department of Gastroenterology, Centre for Immune Regulation, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | | | - Mike Davidson
- Patient Representative & Regional Chairman for Coeliac UK, Sheffield, UK
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Department of Immunology Mayo Clinic, Rochester, Minnesota, USA
| | - Gillian L Swift
- Department of Gastroenterology, University Hospital Llandough, Wales, UK
| | - Marjorie M Walker
- Anatomical Pathology, University of Newcastle, Faculty of Health and Medicine, School of Medicine & Public Health, Callaghan, Australia
| | - Fabiana Zingone
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - David S Sanders
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital & University of Sheffield, Sheffield, UK
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Fernández-Bañares F, Carrasco A, García-Puig R, Rosinach M, González C, Alsina M, Loras C, Salas A, Viver JM, Esteve M. Intestinal intraepithelial lymphocyte cytometric pattern is more accurate than subepithelial deposits of anti-tissue transglutaminase IgA for the diagnosis of celiac disease in lymphocytic enteritis. PLoS One 2014; 9:e101249. [PMID: 25010214 PMCID: PMC4091865 DOI: 10.1371/journal.pone.0101249] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/04/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND & AIMS An increase in CD3+TCRγδ+ and a decrease in CD3- intraepithelial lymphocytes (IEL) is a characteristic flow cytometric pattern of celiac disease (CD) with atrophy. The aim was to evaluate the usefulness of both CD IEL cytometric pattern and anti-TG2 IgA subepithelial deposit analysis (CD IF pattern) for diagnosing lymphocytic enteritis due to CD. METHODS Two-hundred and five patients (144 females) who underwent duodenal biopsy for clinical suspicion of CD and positive celiac genetics were prospectively included. Fifty had villous atrophy, 70 lymphocytic enteritis, and 85 normal histology. Eight patients with non-celiac atrophy and 15 with lymphocytic enteritis secondary to Helicobacter pylori acted as control group. Duodenal biopsies were obtained to assess both CD IEL flow cytometric (complete or incomplete) and IF patterns. RESULTS Sensitivity of IF, and complete and incomplete cytometric patterns for CD diagnosis in patients with positive serology (Marsh 1+3) was 92%, 85 and 97% respectively, but only the complete cytometric pattern had 100% specificity. Twelve seropositive and 8 seronegative Marsh 1 patients had a CD diagnosis at inclusion or after gluten free-diet, respectively. CD cytometric pattern showed a better diagnostic performance than both IF pattern and serology for CD diagnosis in lymphocytic enteritis at baseline (95% vs 60% vs 60%, p = 0.039). CONCLUSIONS Analysis of the IEL flow cytometric pattern is a fast, accurate method for identifying CD in the initial diagnostic biopsy of patients presenting with lymphocytic enteritis, even in seronegative patients, and seems to be better than anti-TG2 intestinal deposits.
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Affiliation(s)
- Fernando Fernández-Bañares
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, University of Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Terrassa (Barcelona), Spain
- * E-mail:
| | - Anna Carrasco
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, University of Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Terrassa (Barcelona), Spain
| | - Roger García-Puig
- Department of Pediatrics, Hospital Universitari Mutua Terrassa, University of Barcelona, Terrassa (Barcelona), Spain
| | - Mercè Rosinach
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, University of Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Terrassa (Barcelona), Spain
| | - Clarisa González
- Department of Pathology, Hospital Universitari Mutua Terrassa, University of Barcelona, CIBERehd, Terrassa (Barcelona), Spain
| | | | - Carme Loras
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, University of Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Terrassa (Barcelona), Spain
| | - Antonio Salas
- Department of Pathology, Hospital Universitari Mutua Terrassa, University of Barcelona, CIBERehd, Terrassa (Barcelona), Spain
| | - Josep M. Viver
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, University of Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Terrassa (Barcelona), Spain
| | - Maria Esteve
- Department of Gastroenterology, Hospital Universitari Mutua Terrassa, University of Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Terrassa (Barcelona), Spain
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