1
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Schiepatti A, Maimaris S, Scarcella C, Pignatti P, Betti E, Shoval Y, Arpa G, Ciccocioppo R, Biagi F. Flow cytometry for the assessment and monitoring of aberrant intraepithelial lymphocytes in non-responsive celiac disease and non-celiac enteropathies. Dig Liver Dis 2024; 56:795-801. [PMID: 37968145 DOI: 10.1016/j.dld.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 10/19/2023] [Accepted: 10/27/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Few data are available on flow cytometry (FC) for monitoring intraepithelial lymphocytes (IELs) in refractory celiac disease (RCD), non-responsive celiac disease (NRCD), and non-celiac enteropathies (NCEs). AIMS 1) To investigate the significance of monitoring IELs immunophenotype with FC in patients with NRCD, RCD and NCEs; 2) to evaluate FC concordance with immunohistochemistry (IHC) and γ-TCR clonality analysis. METHODS Patients investigated between January-2012 and February-2023 were divided into two groups: 1)confirmed RCD or NRCD being investigated for persistent symptoms and suspected complications of celiac disease (CD); 2)NCEs lacking clinical/histological response. Clinical/molecular features and outcomes were retrospectively collected and analysed according to presence/absence of aberrant IELs on FC (cut-off≥20 % CD103+sCD3-CD8-iCD3+ IELs). RESULTS 52 patients (18 RCD,21 NRCD,13 NCEs; 38F, 55±13 years; median follow-up 30 months, IQR 2-58) underwent 100 FC IELs determinations. 22/52 had ≥2 FC determinations and IEL phenotype remained unchanged over time in all them (κ=1.00). Aberrant IEL phenotype in CD was associated with increased mortality (HR 4.2, 95 % CI 1.5-11.9, p < 0.01). No patients with NCEs had an aberrant IEL phenotype at FC, although 3/13 developed lymphoma and 4/13 died. Concordance of FC was fair with both IHC (κ=0.40) and γ-TCR clonality analysis (κ=0.22). CONCLUSION FC is accurate for assessing and monitoring IEL phenotype and providing important prognostic information in celiac patients. Further study is needed on its role in NCEs.
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Affiliation(s)
- Annalisa Schiepatti
- Department of Internal Medicine and Therapeutics, University of Pavia, Italy; Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Italy.
| | - Stiliano Maimaris
- Department of Internal Medicine and Therapeutics, University of Pavia, Italy; Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Italy
| | - Chiara Scarcella
- Department of Internal Medicine and Therapeutics, University of Pavia, Italy
| | - Patrizia Pignatti
- Allergy and Immunology Unit Istituti Clinici Scientifici Maugeri, IRCCS, Pavia, Italy
| | - Elena Betti
- Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Yiftach Shoval
- Department of Internal Medicine and Therapeutics, University of Pavia, Italy
| | - Giovanni Arpa
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Italy; Unit of Anatomic Pathology, ICS Maugeri-IRCCS SpA SB, 27100 Pavia, Italy
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata Policlinico G.B. Rossi and University of Verona, Verona, Italy
| | - Federico Biagi
- Department of Internal Medicine and Therapeutics, University of Pavia, Italy; Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, Italy
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2
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Malamut G, Soderquist CR, Bhagat G, Cerf-Bensussan N. Advances in Nonresponsive and Refractory Celiac Disease. Gastroenterology 2024:S0016-5085(24)00360-3. [PMID: 38556189 DOI: 10.1053/j.gastro.2024.02.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/04/2024] [Accepted: 02/20/2024] [Indexed: 04/02/2024]
Abstract
Nonresponsive celiac disease (CeD) is relatively common. It is generally attributed to persistent gluten exposure and resolves after correction of diet errors. However, other complications of CeD and disorders clinically mimicking CeD need to be excluded. Novel therapies are being evaluated to facilitate mucosal recovery, which might benefit patients with nonresponsive CeD. Refractory CeD (RCeD) is rare and is divided into 2 types. The etiology of type I RCeD is unclear. A switch to gluten-independent autoimmunity is suspected in some patients. In contrast, type II RCeD represents a low-grade intraepithelial lymphoma. Type I RCeD remains a diagnosis of exclusion, requiring ruling out gluten intake and other nonmalignant causes of villous atrophy. Diagnosis of type II RCeD relies on the demonstration of a clonal population of neoplastic intraepithelial lymphocytes with an atypical immunophenotype. Type I RCeD and type II RCeD generally respond to open-capsule budesonide, but the latter has a dismal prognosis due to severe malnutrition and frequent progression to enteropathy-associated T-cell lymphoma; more efficient therapy is needed.
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Affiliation(s)
- Georgia Malamut
- Department of Gastroenterology, Assistance Publique-Hôpitaux de Paris Centre-Université Paris Cité, Hôpital Cochin, Paris, France; Laboratory of Intestinal Immunity, INSERM UMR 1163-Institut Imagine, Université Paris Cité, Paris, France.
| | - Craig R Soderquist
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Govind Bhagat
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Nadine Cerf-Bensussan
- Laboratory of Intestinal Immunity, INSERM UMR 1163-Institut Imagine, Université Paris Cité, Paris, France.
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3
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Elli L, Leffler D, Cellier C, Lebwohl B, Ciacci C, Schumann M, Lundin KEA, Chetcuti Zammit S, Sidhu R, Roncoroni L, Bai JC, Lee AR, Dennis M, Robert ME, Rostami K, Khater S, Comino I, Cebolla A, Branchi F, Verdu EF, Stefanolo JP, Wolf R, Bergman-Golden S, Trott N, Scudeller L, Zingone F, Scaramella L, Sanders DS. Guidelines for best practices in monitoring established coeliac disease in adult patients. Nat Rev Gastroenterol Hepatol 2024; 21:198-215. [PMID: 38110546 DOI: 10.1038/s41575-023-00872-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 12/20/2023]
Abstract
Coeliac disease (CeD) is an immunological disease triggered by the consumption of gluten contained in food in individuals with a genetic predisposition. Diagnosis is based on the presence of small bowel mucosal atrophy and circulating autoantibodies (anti-type 2 transglutaminase antibodies). After diagnosis, patients follow a strict, life-long gluten-free diet. Although the criteria for diagnosis of this disease are well defined, the monitoring phase has been studied less and there is a lack of specific guidelines for this phase. To develop a set of clinical guidelines for CeD monitoring, we followed the Grading of Recommendations Assessment, Development and Evaluation methodology. Statements and recommendations with the level of evidence were developed and approved by the working group, which comprised gastroenterologists, pathologists, dieticians and biostatisticians. The proposed guidelines, endorsed by the North American and European coeliac disease scientific societies, make recommendations for best practices in monitoring patients with CeD based on the available evidence. The evidence level is low for many topics, suggesting that further research in specific aspects of CeD would be valuable. In conclusion, the present guidelines support clinicians in improving CeD treatment and follow-up and highlight novel issues that should be considered in future studies.
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Affiliation(s)
- Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease-Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Daniel Leffler
- Celiac Center, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, MA, USA
| | - Christophe Cellier
- Department of Gastroenterology and Endoscopy, CELAC network, AP-HP Centre, Hôpital Européen Georges Pompidou, Université de Paris, Cité and Institut National du Cancer, Paris, France
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University Irving Medical Center, Columbia University, New York, NY, USA
| | - Carolina Ciacci
- Center for Celiac Disease, Gastrointestinal Unit, AOU San Giovanni di Dio e Ruggi D'Aragona and Department of Medicine Surgery Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno, Italy
| | - Michael Schumann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Berlin, Germany
| | - Knut E A Lundin
- K.G. Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | | | - Reena Sidhu
- Department of Infection, Immunity and Cardiovascular Diseases, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Leda Roncoroni
- Center for Prevention and Diagnosis of Celiac Disease-Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Julio C Bai
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Anne R Lee
- Celiac Disease Center, Department of Medicine, Columbia University Irving Medical Center, Columbia University, New York, NY, USA
| | - Melinda Dennis
- Celiac Center, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, MA, USA
| | - Marie E Robert
- Department of Pathology and Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kamran Rostami
- Department of Gastroenterology, Palmerston North District Health Board (DHB), Palmerston North, New Zealand
| | - Sherine Khater
- Department of Gastroenterology and Endoscopy, CELAC network, AP-HP Centre, Hôpital Européen Georges Pompidou, Université de Paris, Cité and Institut National du Cancer, Paris, France
| | - Isabel Comino
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | | | - Federica Branchi
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Berlin, Germany
| | - Elena F Verdu
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Juan Pablo Stefanolo
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires, Argentina
| | - Randi Wolf
- Program in Nutrition, Department of Health Studies & Applied Educational Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Sheba Bergman-Golden
- Program in Nutrition, Department of Health Studies & Applied Educational Psychology, Teachers College, Columbia University, New York, NY, USA
| | - Nick Trott
- Department of Infection, Immunity and Cardiovascular Diseases, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Luigia Scudeller
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fabiana Zingone
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale-Università Padova, Padua, Italy
| | - Lucia Scaramella
- Center for Prevention and Diagnosis of Celiac Disease-Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - David S Sanders
- Department of Infection, Immunity and Cardiovascular Diseases, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
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4
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Patt YS, Lahat A, David P, Patt C, Eyade R, Sharif K. Unraveling the Immunopathological Landscape of Celiac Disease: A Comprehensive Review. Int J Mol Sci 2023; 24:15482. [PMID: 37895160 PMCID: PMC10607730 DOI: 10.3390/ijms242015482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 10/20/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023] Open
Abstract
Celiac disease (CD) presents a complex interplay of both innate and adaptive immune responses that drive a variety of pathological manifestations. Recent studies highlight the role of immune-mediated pathogenesis, pinpointing the involvement of antibodies against tissue transglutaminases (TG2, TG3, TG6), specific HLA molecules (DQ2/8), and the regulatory role of interleukin-15, among other cellular and molecular pathways. These aspects illuminate the systemic nature of CD, reflecting its wide-reaching impact that extends beyond gastrointestinal symptoms to affect other physiological systems and giving rise to a range of pathological landscapes, including refractory CD (RCD) and, in severe cases, enteropathy-associated T cell lymphoma. The existing primary therapeutic strategy, a gluten-free diet (GFD), poses significant challenges, such as low adherence rates, necessitating alternative treatments. Emerging therapies target various stages of the disease pathology, from preventing immunogenic gluten peptide absorption to enhancing intestinal epithelial integrity and modulating the immune response, heralding potential breakthroughs in CD management. As the understanding of CD deepens, novel therapeutic avenues are emerging, paving the way for more effective and sophisticated treatment strategies with the aim of enhancing the quality of life of CD patients. This review aims to delineate the immunopathology of CD and exploring its implications on other systems, its complications and the development of novel treatments.
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Affiliation(s)
- Yonatan Shneor Patt
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
| | - Adi Lahat
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Paula David
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
| | - Chen Patt
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- The Adelson School of Medicine, Ariel University, Ariel 40700, Israel
| | - Rowand Eyade
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
| | - Kassem Sharif
- Department of Internal Medicine B, Sheba Medical Center, Ramat Gan 52621, Israel; (Y.S.P.); (P.D.); (C.P.); (R.E.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan 52621, Israel
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5
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Artificial Intelligence Analysis of Celiac Disease Using an Autoimmune Discovery Transcriptomic Panel Highlighted Pathogenic Genes including BTLA. Healthcare (Basel) 2022; 10:healthcare10081550. [PMID: 36011206 PMCID: PMC9408070 DOI: 10.3390/healthcare10081550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/09/2022] [Accepted: 08/14/2022] [Indexed: 12/18/2022] Open
Abstract
Celiac disease is a common immune-related inflammatory disease of the small intestine caused by gluten in genetically predisposed individuals. This research is a proof-of-concept exercise focused on using Artificial Intelligence (AI) and an autoimmune discovery gene panel to predict and model celiac disease. Conventional bioinformatics, gene set enrichment analysis (GSEA), and several machine learning and neural network techniques were used on a publicly available dataset (GSE164883). Machine learning and deep learning included C5, logistic regression, Bayesian network, discriminant analysis, KNN algorithm, LSVM, random trees, SVM, Tree-AS, XGBoost linear, XGBoost tree, CHAID, Quest, C&R tree, random forest, and neural network (multilayer perceptron). As a result, the gene panel predicted celiac disease with high accuracy (95–100%). Several pathogenic genes were identified, some of the immune checkpoint and immuno-oncology pathways. They included CASP3, CD86, CTLA4, FASLG, GZMB, IFNG, IL15RA, ITGAX, LAG3, MMP3, MUC1, MYD88, PRDM1, RGS1, etc. Among them, B and T lymphocyte associated (BTLA, CD272) was highlighted and validated at the protein level by immunohistochemistry in an independent series of cases. Celiac disease was characterized by high BTLA, expressed by inflammatory cells of the lamina propria. In conclusion, artificial intelligence predicted celiac disease using an autoimmune discovery gene panel.
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6
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Felber J, Bläker H, Fischbach W, Koletzko S, Laaß M, Lachmann N, Lorenz P, Lynen P, Reese I, Scherf K, Schuppan D, Schumann M, Aust D, Baas S, Beisel S, de Laffolie J, Duba E, Holtmeier W, Lange L, Loddenkemper C, Moog G, Rath T, Roeb E, Rubin D, Stein J, Török H, Zopf Y. Aktualisierte S2k-Leitlinie Zöliakie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:790-856. [PMID: 35545109 DOI: 10.1055/a-1741-5946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Jörg Felber
- Medizinische Klinik II - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Hendrik Bläker
- Institut für Pathologie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | | | - Sibylle Koletzko
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU-Klinikum München, München, Deutschland.,Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, 10-719 Olsztyn, Polen
| | - Martin Laaß
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - Nils Lachmann
- Institut für Transfusionsmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Pia Lorenz
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Petra Lynen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Imke Reese
- Ernährungsberatung und -therapie Allergologie, München, Deutschland
| | - Katharina Scherf
- Institute of Applied Biosciences Department of Bioactive and Functional Food Chemistry, Karlsruhe Institute of Technology (KIT), Karlsruhe, Deutschland
| | - Detlef Schuppan
- Institut für Translationale Immunologie, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland.,Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michael Schumann
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
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7
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Oka P, Sidhu R. Small bowel lymphoma: clinical update and challenges for the gastroenterologist. Curr Opin Gastroenterol 2022; 38:270-278. [PMID: 35275901 DOI: 10.1097/mog.0000000000000829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW The diagnosis of small bowel lymphoma (SBL) can be challenging, as they are very rare and also have a varied presentation. In this review, we aim to provide a broad overview of the types of SBL and also about the various modalities used for their diagnosis. We also discuss the overview of treatment strategies for a gastroenterologist. RECENT FINDINGS Small bowel capsule endoscopy (SBCE) and devise-assisted enteroscopy (DAE) has revolutionized the way we investigate the small bowel. DAE also makes it possible to obtain histological samples for further characterization of SBL. This has led to a significant improvement in diagnosis and management of the disease in conjunction with cross-sectional imagining. SUMMARY The diagnosis and management of small bowel lymphoma remains challenging despite the development of newer techniques such as SBCE and DAE. The current available diagnostic modalities have limitations; in the absence of a gold standard, the current investigative modalities compliment each other in reaching the final diagnosis.
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Affiliation(s)
- Priya Oka
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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8
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Abstract
Celiac disease is a chronic, immune-mediated enteropathy driven by dietary gluten found in genetically susceptible hosts. It has a worldwide distribution, is one of the most common autoimmune disorders globally, and is the only autoimmune condition for which the trigger is known. Despite advances in characterizing mechanisms of disease, gaps in understanding of celiac disease pathogenesis remain. A "frontier" concept is considering what moves an HLA-DQ2 or DQ8-positive individual from asymptomatic gluten tolerance to celiac disease manifestation. In this arena, environmental triggers, including age at the time of initial gluten exposure, the occurrence of usual childhood viral infections, and microbiome alterations have emerged as key events in triggering the symptomatic disease. Pathologists play a major role in frontier aspects of celiac disease. This includes the discovery that duodenal mucosal histology in follow-up biopsies does not correlate with ongoing patient symptoms, antitissue transglutaminase antibody titers and diet adherence in celiac disease patients. Further, in light of recent evidence that the detection of monoclonal T-cell populations in formalin-fixed biopsies is not specific for type II refractory celiac disease, pathologists should resist performing such analyses until common causes of "apparent" refractoriness are excluded. The promise of therapies in celiac disease has led to clinical trials targeting many steps in the inflammatory cascade, which depend upon a pathologist's confirmation of the initial diagnosis and evaluation of responses to therapies. As pathologists continue to be active participants in celiac disease research, partnering with other stakeholders, we will continue to impact this important autoimmune disease.
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Affiliation(s)
- Natalie Patel
- El Camino Pathology Medical Group, Mountain View, CA
| | - Marie E Robert
- Department of Pathology and Medicine, Yale University School of Medicine, New Haven, CT
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9
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Pelizzaro F, Marsilio I, Fassan M, Piazza F, Barberio B, D’Odorico A, Savarino EV, Farinati F, Zingone F. The Risk of Malignancies in Celiac Disease-A Literature Review. Cancers (Basel) 2021; 13:cancers13215288. [PMID: 34771450 PMCID: PMC8582432 DOI: 10.3390/cancers13215288] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 12/14/2022] Open
Abstract
Celiac disease (CeD) is an immune-mediated enteropathy precipitated by ingestion of gluten in genetically predisposed individuals. Considering that CeD affects approximately 1% of the Western population, it may be considered a global health problem. In the large majority of cases, CeD has a benign course, characterized by the complete resolution of symptoms and a normal life expectancy after the beginning of a gluten-free-diet (GFD); however, an increased risk of developing malignancies, such as lymphomas and small bowel carcinoma (SBC), has been reported. In particular, enteropathy-associated T-cell lymphoma (EATL), a peculiar type of T-cell lymphoma, is characteristically associated with CeD. Moreover, the possible association between CeD and several other malignancies has been also investigated in a considerable number of studies. In this paper, we aim to provide a comprehensive review of the current knowledge about the associations between CeD and cancer, focusing in particular on EATL and SBC, two rare but aggressive malignancies.
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Affiliation(s)
- Filippo Pelizzaro
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (F.P.); (I.M.); (B.B.); (A.D.); (E.V.S.); (F.F.)
| | - Ilaria Marsilio
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (F.P.); (I.M.); (B.B.); (A.D.); (E.V.S.); (F.F.)
| | - Matteo Fassan
- Surgical Pathology and Cytopathology Unit, Department of Medicine (DIMED), University Hospital of Padova, 35128 Padova, Italy;
- Veneto Oncology Institute, IOV-IRCCS, 35128 Padova, Italy
| | - Francesco Piazza
- Department of Medicine, Hematology, University Hospital of Padova, 35128 Padova, Italy;
| | - Brigida Barberio
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (F.P.); (I.M.); (B.B.); (A.D.); (E.V.S.); (F.F.)
| | - Anna D’Odorico
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (F.P.); (I.M.); (B.B.); (A.D.); (E.V.S.); (F.F.)
| | - Edoardo V. Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (F.P.); (I.M.); (B.B.); (A.D.); (E.V.S.); (F.F.)
| | - Fabio Farinati
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (F.P.); (I.M.); (B.B.); (A.D.); (E.V.S.); (F.F.)
| | - Fabiana Zingone
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padova, 35128 Padova, Italy; (F.P.); (I.M.); (B.B.); (A.D.); (E.V.S.); (F.F.)
- Correspondence:
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10
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Soldera J, Salgado K, Pêgas KL. Refractory celiac disease type 2: how to diagnose and treat? Rev Assoc Med Bras (1992) 2021; 67:168-172. [PMID: 34406238 DOI: 10.1590/1806-9282.67.02.20200618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/16/2020] [Indexed: 11/22/2022] Open
Abstract
Refractory celiac disease is an uncommon condition which might be associated to poor prognosis. It is often treated with immunosuppressive medications, with poor results. It is divided in type 1 and type 2, the latter carrying a high risk for lymphoma and mortality. A case of a 41 year old female patient with refractory celiac disease type 2 is reported. She was treated with oral budesonide for six months, achieving histological remission.
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Affiliation(s)
| | - Karina Salgado
- Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brazil
| | - Karla Lais Pêgas
- Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brazil.,Irmandade Santa Casa de Misericórdia de Porto Alegre - Porto Alegre (RS), Brazil
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Zammit SC, Elli L, Scaramella L, Sanders DS, Tontini GE, Sidhu R. Small bowel capsule endoscopy in refractory celiac disease: a luxury or a necessity? Ann Gastroenterol 2021; 34:188-195. [PMID: 33654358 PMCID: PMC7903573 DOI: 10.20524/aog.2021.0586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 10/27/2020] [Indexed: 12/11/2022] Open
Abstract
Background Small bowel capsule endoscopy (SBCE) has an established role in the management of refractory celiac disease (RCD) for the detection of complications. The aim of this study was to define the role of SBCE in the management of patients with RCD. Method Patients with histologically confirmed RCD who underwent successive SBCEs were recruited retrospectively from 2 tertiary centers. Results Sixty patients with RCD were included. The percentage extent of the affected small bowel (SB) mucosa improved on repeating a second SBCE in 26 patients (49.1%) (median 27.6% vs. 18.1%, P=0.007). Patients with RCD type II had more extensive disease than those with RCD type I on first (41.4% vs. 19.2%, P=0.004) and second (29.8% vs. 12.0%, P=0.016) SBCE. Patients with RCD type I tended to show a greater improvement in percentage of abnormal SB involved on repeat SBCE compared to those with RCD type II (P=0.049). Nine patients (15%) had RCD-related complications. Five patients developed ulcerative jejunoileitis, 3 patients developed enteropathy-associated T-cell lymphoma, and 1 patient developed cutaneous T-cell lymphoma. Conclusions SBCE can be a useful tool for monitoring the effects of treatment, primarily following its initiation. Patients with RCD type II have more extensive SB disease, equating to a more aggressive disease pattern.
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Affiliation(s)
- Stefania Chetcuti Zammit
- Gastroenterology Department, Sheffield Teaching Hospitals, United Kingdom (Stefania Chetcuti Zammit, David S. Sanders, Reena Sidhu)
| | - Luca Elli
- Centre for Prevention and Diagnosis of Coeliac Disease, Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Italy (Luca Elli, Lucia Scaramella, Gian Eugenio Tontini)
| | - Lucia Scaramella
- Centre for Prevention and Diagnosis of Coeliac Disease, Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Italy (Luca Elli, Lucia Scaramella, Gian Eugenio Tontini)
| | - David S Sanders
- Gastroenterology Department, Sheffield Teaching Hospitals, United Kingdom (Stefania Chetcuti Zammit, David S. Sanders, Reena Sidhu)
| | - Gian Eugenio Tontini
- Centre for Prevention and Diagnosis of Coeliac Disease, Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Italy (Luca Elli, Lucia Scaramella, Gian Eugenio Tontini)
| | - Reena Sidhu
- Gastroenterology Department, Sheffield Teaching Hospitals, United Kingdom (Stefania Chetcuti Zammit, David S. Sanders, Reena Sidhu)
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Cellular and molecular bases of refractory celiac disease. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2021; 358:207-240. [PMID: 33707055 DOI: 10.1016/bs.ircmb.2020.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Refractory celiac disease (RCD) encompasses biologically heterogeneous disorders that develop in a small proportion (0.3%) of individuals with celiac disease that are associated with high morbidity. Two broad categories are currently recognized, type I (RCD I) and type II (RCD II), based on immunophenotypic and molecular features of the intraepithelial lymphocytes (IELs). RCD I is characterized by a polyclonal expansion of IELs displaying a normal immunophenotype, while RCD II represents a clonal proliferation of immunophenotypically "aberrant" IELs, and is considered a low-grade lymphoproliferative disorder. The pathogenesis of RCD I has not been clarified, but limited studies suggest multifactorial etiology. On the other hand, recent immunologic, molecular and immunophenotypic analyses have proposed lineage-negative innate IELs to be the cell of origin of a proportion of RCD II cases. Furthermore, sequencing studies have identified frequent, recurrent, activating mutations in members of the JAK-STAT pathway in RCD II. This finding, in conjunction with prior in vitro experimental observations, suggests roles of deregulated cytokine signaling in disease pathogenesis. In this review, we describe current understanding of environmental, immune and genetic factors associated with the development of RCD and briefly discuss diagnostic and therapeutic considerations.
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Clinical phenotype and mortality in patients with idiopathic small bowel villous atrophy: a dual-centre international study. Eur J Gastroenterol Hepatol 2020; 32:938-949. [PMID: 32282540 DOI: 10.1097/meg.0000000000001726] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Causes of small-bowel villous atrophy (VA) include coeliac disease (CD), its complications and other rare non-coeliac enteropathies. However, forms of VA of unknown aetiology may also exist. We defined them as idiopathic VA (IVA). To retrospectively classify the largest cohort of IVA patients and compare their natural history with CD. METHODS Notes of 76 IVA patients attending two tertiary centres between January 2000 and March 2019 were retrospectively reviewed. CD, its complications and all the known causes of VA were excluded in all of them. Persistence of VA during follow-up and lymphoproliferative features were used to retrospectively classify IVA, as follows. Group 1: IVA with spontaneous histological recovery (50 patients). Group 2: persistent IVA without lymphoproliferative features (14 patients). Group 3: persistent IVA with lymphoproliferative features (12 patients). Survival was compared between IVA groups and 1114 coeliac patients. HLA was compared between IVA patients, coeliac patients and appropriate controls. RESULTS Five-year survival was 96% in IVA group 1, 100% in IVA group 2, 27% in IVA group 3 and 97% in CD. On a multivariate analysis hypoalbuminemia (P = 0.002) and age at diagnosis (P = 0.04) predicted mortality in IVA. Group 2 showed association with HLA DQB1*0301 and DQB1*06. CONCLUSION IVA consists of three groups of enteropathies with distinct clinical phenotypes and prognoses. Mortality in IVA is higher than in CD and mainly due to lymphoproliferative conditions necessitating more aggressive therapies.
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Wei X, Zhang L, Zhang R, Koci M, Si D, Ahmad B, Cheng J, Wang J, Aihemaiti M, Zhang M. A Novel Cecropin-LL37 Hybrid Peptide Protects Mice Against EHEC Infection-Mediated Changes in Gut Microbiota, Intestinal Inflammation, and Impairment of Mucosal Barrier Functions. Front Immunol 2020; 11:1361. [PMID: 32695115 PMCID: PMC7338479 DOI: 10.3389/fimmu.2020.01361] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/28/2020] [Indexed: 12/14/2022] Open
Abstract
Intestinal inflammation can cause impaired epithelial barrier function and disrupt immune homeostasis, which increases the risks of developing many highly fatal diseases. Enterohemorrhagic Escherichia coli (EHEC) O157:H7 causes intestinal infections worldwide and is a major pathogen that induces intestinal inflammation. Various antibacterial peptides have been described as having the potential to suppress and treat pathogen-induced intestinal inflammation. Cecropin A (1–8)-LL37 (17–30) (C-L), a novel hybrid peptide designed in our laboratory that combines the active center of C with the core functional region of L, shows superior antibacterial properties and minimized cytotoxicity compared to its parental peptides. Herein, to examine whether C-L could inhibit pathogen-induced intestinal inflammation, we investigated the anti-inflammatory effects of C-L in EHEC O157:H7-infected mice. C-L treatment improved the microbiota composition and microbial community balance in mouse intestines. The hybrid peptide exhibited improved anti-inflammatory effects than did the antibiotic, enrofloxacin. Hybrid peptide treated infected mice demonstrated reduced clinical signs of inflammation, reduced weight loss, reduced expression of pro-inflammatory cytokines [tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and interferon-gamma (IFN-γ)], reduced apoptosis, and reduced markers of jejunal epithelial barrier function. The peptide also affected the MyD88–nuclear factor κB signaling pathway, thereby modulating inflammatory responses upon EHEC stimulation. Collectively, these findings suggest that the novel hybrid peptide C-L could be developed into a new anti-inflammatory agent for use in animals or humans.
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Affiliation(s)
- Xubiao Wei
- Laboratory of Feed Biotechnology, State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Lulu Zhang
- Laboratory of Feed Biotechnology, State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Rijun Zhang
- Laboratory of Feed Biotechnology, State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Matthew Koci
- Prestage Department of Poultry Science, College of Agriculture and Life Sciences, North Carolina State University, Raleigh, NC, United States
| | - Dayong Si
- Laboratory of Feed Biotechnology, State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Baseer Ahmad
- Laboratory of Feed Biotechnology, State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Junhao Cheng
- Laboratory of Feed Biotechnology, State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Junyong Wang
- Laboratory of Feed Biotechnology, State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Maierhaba Aihemaiti
- Laboratory of Feed Biotechnology, State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Manyi Zhang
- Laboratory of Feed Biotechnology, State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
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Abstract
PURPOSE OF REVIEW The aim of this review is to provide insight into the diagnosis and management of patients with refractory coeliac disease (RCD) and highlight recent advances in this field. RECENT FINDINGS The diagnosis of RCD can be more accurately confirmed with flow cytometry in addition to immunohistochemistry. Dietary input and excretion of gluten immunogenic peptides can help rule out gluten contamination, and therefore, substantiate a diagnosis of RCD type I. Small bowel capsule endoscopy (SBCE) is important at diagnosis and follow-up in addition to duodenal histology. Apart from ruling out complications, it can give information on extent of disease in the small bowel, and therefore, help assess response to therapy. Those patients with a poor response can have earlier intensification of therapy, which may result in an improved outcome. RCD also occurs in patients with serology negative coeliac disease but with an increased mortality compared with patients with serology-positive coeliac disease. SUMMARY Patients with RCD can present with persistent symptoms of malnutrition but can also be completely asymptomatic. Serology is not a reliable marker to detect refractory disease. Immunostaining and flow cytometry are necessary for a diagnosis of RCD. Small bowel endoscopy enables disease extent to be assessed and allows for small bowel biopsies to be taken in case of suspicious lesions. Small bowel radiology can be complementary to small bowel endoscopy.
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Penny HA, Baggus EMR, Rej A, Snowden JA, Sanders DS. Non-Responsive Coeliac Disease: A Comprehensive Review from the NHS England National Centre for Refractory Coeliac Disease. Nutrients 2020; 12:E216. [PMID: 31947666 PMCID: PMC7019917 DOI: 10.3390/nu12010216] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/06/2020] [Accepted: 01/09/2020] [Indexed: 02/06/2023] Open
Abstract
Coeliac disease is a common small intestinal enteropathy which manifests following ingestion of gluten in genetically susceptible individuals. Since gluten was identified as the driving factor in coeliac disease, the gluten-free diet (GFD) has remained the mainstay of treatment. While most individuals will display improvement in symptoms and signs of coeliac disease following institution of the GFD, up to 30% will continue to experience symptoms and/or have persisting intestinal inflammation. These individuals can be classified as having non-responsive coeliac disease (NRCD), which may be associated with dietary indiscretion, slow healing, refractory coeliac disease, and/or an alternative condition. The purpose of this review is to provide an overview of the causes of NRCD in adults, highlight a systematic approach to investigate these patients, and appraise the latest management aspects of this subset of coeliac disease.
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Affiliation(s)
- Hugo A. Penny
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
- Lydia Becker Institute of Inflammation and Immunology, University of Manchester, Manchester M13 9PL, UK
| | - Elisabeth M. R. Baggus
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
| | - Anupam Rej
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
| | - John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK;
| | - David S. Sanders
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
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Clinical Insignficance of Monoclonal T-Cell Populations and Duodenal Intraepithelial T-Cell Phenotypes in Celiac and Nonceliac Patients. Am J Surg Pathol 2019; 43:151-160. [PMID: 30334829 DOI: 10.1097/pas.0000000000001172] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Refractory celiac disease (RCD) is a rare condition, usually managed at specialized centers. However, gastroenterologists and pathologists in general practices are often the first to consider a diagnosis of RCD in celiac patients with persistent symptoms. The distinction between type I and type II RCD is crucial as patients with RCD II have a shortened life expectancy. The diagnosis of RCD II requires the demonstration of abnormal intraepithelial lymphocytes and/or monoclonal T-cell populations in duodenal biopsies, typically assessed in formalin-fixed paraffin-embedded tissue. We investigated the clinical significance of T-cell receptor gene rearrangements and CD3/CD8 staining in formalin-fixed paraffin-embedded biopsies from 32 patients with RCD I (4), RCD II (3), newly diagnosed celiac disease (CD) (10), established CD patients with follow-up biopsies (10), and Helicobacter pylori-associated lymphocytosis (5). Clonal T-cell populations were present in all lymphocytosis groups but not in normal controls. No difference in the frequency of clonal populations or persistence of identical clones was found between RCD I and II patients. The degree of villous blunting did not correlate with clonal status in any group. No difference in the number of CD3/CD8-positive intraepithelial lymphocytes per 100 enterocytes was found between groups. We suggest that clonal evaluation of T cells should not be employed routinely in the evaluation of CD patients with persistent symptoms until common causes of "apparent refractoriness" have been excluded. In addition, lymphocyte phenotyping and T-cell clonal analysis appear to be insufficient as stand-alone tests to reliably distinguish RCD I and II.
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18
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Baggus EMR, Hadjivassiliou M, Cross S, Penny H, Urwin H, Watson S, Woodward JM, Sanders DS. How to manage adult coeliac disease: perspective from the NHS England Rare Diseases Collaborative Network for Non-Responsive and Refractory Coeliac Disease. Frontline Gastroenterol 2019; 11:235-242. [PMID: 32419915 PMCID: PMC7223293 DOI: 10.1136/flgastro-2019-101191] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/03/2019] [Accepted: 07/21/2019] [Indexed: 02/06/2023] Open
Abstract
Adult coeliac disease (CD) affects approximately 1% of the population. Most patients diagnosed will respond to a gluten-free diet; however, up to 30% may have persisting symptoms. Such patients may have ongoing issues associated with adherence, non-responsive CD or refractory CD. This article provides a clinical overview of how to manage this group of patients with persisting symptoms, including an investigational algorithm and details of how to contact the National Health Service England Rare Diseases Collaborative Network for Non-Responsive and Refractory Coeliac Disease. We hope this will be a valuable source of contemporary information for all UK gastroenterologists and internationally.
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Affiliation(s)
| | | | - Simon Cross
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Hugo Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Heidi Urwin
- Coeliac UK, High Wycombe, Buckinghamshire, UK
| | - Sarah Watson
- Highly Specialised Services, NHS England, England, UK
| | - Jeremy Mark Woodward
- Department of Gastroenterology, Cambridge Intestinal Failure and Transplant, Cambridge, UK
| | - David S Sanders
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
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Chetcuti Zammit S, Sanders DS, Sidhu R. A comprehensive review on the utility of capsule endoscopy in coeliac disease: From computational analysis to the bedside. Comput Biol Med 2018; 102:300-314. [PMID: 29980284 DOI: 10.1016/j.compbiomed.2018.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/23/2018] [Accepted: 06/24/2018] [Indexed: 11/29/2022]
Abstract
Small bowel capsule endoscopy (SBCE) can identify macroscopic changes of coeliac disease and assess the extent of disease in the small bowel beyond the duodenum. SBCE has a good sensitivity for the detection of coeliac disease in comparison to histology owing to several ideal features such as a high magnification. It also plays a useful role in detecting complications in patients with refractory coeliac disease. Several studies have been carried out on transforming images obtained from small bowel capsule endoscopy to enable the automated detection of features related to coeliac disease. This review discusses the current roles played by small bowel capsule endoscopy in coeliac disease. It identifies future potential roles of this technique and describes in great detail the role of computational analysis in the detection of coeliac disease and how it can be adapted to current available technology.
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Affiliation(s)
- Stefania Chetcuti Zammit
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK.
| | - David S Sanders
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
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Chetcuti Zammit S, Sanders DS, Sidhu R. Capsule endoscopy for patients with coeliac disease. Expert Rev Gastroenterol Hepatol 2018; 12:779-790. [PMID: 29886766 DOI: 10.1080/17474124.2018.1487289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Coeliac disease is an autoimmune mediated condition in response to gluten. A combination of innate and adaptive immune responses results in villous shortening in the small bowel (SB) that can be morphologically picked up on capsule endoscopy. It is the only imaging modality that can provide mucosal views of the entire SB, while histology is generally limited to the proximal SB. Radiological modalities are not designed to pick up changes in villous morphology. Areas covered: In this review, we provide a comprehensive analysis on the justified use of small bowel capsule endoscopy (SBCE) in the assessment of patients with coeliac disease; compare SBCE to histology, serology, and symptomatology; and provide an overview on automated quantitative analysis for the detection of coeliac disease. We also provide insight into future work on SBCE in relation to coeliac disease. Expert commentary: SBCE has opened up new avenues for the diagnosis and monitoring of patients with coeliac disease. However, larger studies with new and established coeliac disease patients and with greater emphasis on morphological features on SBCE are required to better define the role of SBCE in the setting of coeliac disease.
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Affiliation(s)
| | - David S Sanders
- a Gastroenterology Department , Sheffield Teaching Hospitals , Sheffield , UK
| | - Reena Sidhu
- a Gastroenterology Department , Sheffield Teaching Hospitals , Sheffield , UK
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21
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Hussein S, Gindin T, Lagana SM, Arguelles-Grande C, Krishnareddy S, Alobeid B, Lewis SK, Mansukhani MM, Green PHR, Bhagat G. Clonal T cell receptor gene rearrangements in coeliac disease: implications for diagnosing refractory coeliac disease. J Clin Pathol 2018; 71:825-831. [DOI: 10.1136/jclinpath-2018-205023] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/31/2022]
Abstract
AimsRefractory coeliac disease type II (RCDII), a rare complication of coeliac disease (CD) associated with high morbidity, requires identification of a clonal population of phenotypically aberrant intraepithelial lymphocytes (IELs) for diagnosis. However, data regarding the frequency and significance of clonal T cell receptor (TCR) gene rearrangements (TCR-GRs) in small bowel (SB) biopsies of patients without RCDII are limited.MethodsWe analysed results of TCR-GR analyses performed on SB biopsies at our institution over a 3-year period, which were obtained from eight active CD, 172 CD on gluten-free diet (GFD), 33 RCDI, and three RCDII patients and 14 patients without CD. TCR-GR patterns were divided into clonal, polyclonal and prominent clonal peaks (PCPs) and these patterns were correlated with clinical and pathological features.ResultsClonal TCR-GR products were detected in biopsies from 67% of patients with RCDII, 17% of patients with RCDI and 6% of patients with GFD. PCPs were observed in all disease phases (range 12%–33%). There was no significant difference in the TCR-GR patterns between the non-RCDII disease categories (p=0.39). A higher frequency of surface CD3(−) IELs was noted in cases with clonal TCR-GR, but the PCP pattern did not show associations with any clinical or pathological feature. Persistence of clonal or PCP pattern on repeat biopsy was seen for up to 2 years without evidence of RCDII.ConclusionsClonal TCR-GRs are not infrequent in cases lacking features of RCDII, while PCPs are frequent in all disease phases. TCR-GR results should be assessed in conjunction with immunophenotypic, histological and clinical findings for appropriate diagnosis and classification of RCD.
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22
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Rubio-Tapia A, Malamut G, Verbeek WH, van Wanrooij RL, Leffler DA, Niveloni SI, Arguelles-Grande C, Lahr BD, Zinsmeister AR, Murray JA, Kelly CP, Bai JC, Green PH, Daum S, Mulder CJ, Cellier C. Creation of a model to predict survival in patients with refractory coeliac disease using a multinational registry. Aliment Pharmacol Ther 2016; 44:704-14. [PMID: 27485029 PMCID: PMC5018234 DOI: 10.1111/apt.13755] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/09/2016] [Accepted: 07/14/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Refractory coeliac disease is a severe complication of coeliac disease with heterogeneous outcome. AIM To create a prognostic model to estimate survival of patients with refractory coeliac disease. METHODS We evaluated predictors of 5-year mortality using Cox proportional hazards regression on subjects from a multinational registry. Bootstrap resampling was used to internally validate the individual factors and overall model performance. The mean of the estimated regression coefficients from 400 bootstrap models was used to derive a risk score for 5-year mortality. RESULTS The multinational cohort was composed of 232 patients diagnosed with refractory coeliac disease across seven centres (range of 11-63 cases per centre). The median age was 53 years and 150 (64%) were women. A total of 51 subjects died during a 5-year follow-up (cumulative 5-year all-cause mortality = 30%). From a multiple variable Cox proportional hazards model, the following variables were significantly associated with 5-year mortality: age at refractory coeliac disease diagnosis (per 20 year increase, hazard ratio = 2.21; 95% confidence interval, CI: 1.38-3.55), abnormal intraepithelial lymphocytes (hazard ratio = 2.85; 95% CI: 1.22-6.62), and albumin (per 0.5 unit increase, hazard ratio = 0.72; 95% CI: 0.61-0.85). A simple weighted three-factor risk score was created to estimate 5-year survival. CONCLUSIONS Using data from a multinational registry and previously reported risk factors, we create a prognostic model to predict 5-year mortality among patients with refractory coeliac disease. This new model may help clinicians to guide treatment and follow-up.
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Affiliation(s)
| | | | | | | | - Daniel A. Leffler
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | | | | | | | | | | | - Ciaran P. Kelly
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Julio C. Bai
- Hospital Dr. Carlos Nonorino Udaondo, Buenos Aires, Argentina
| | - Peter H. Green
- Columbia University Medical Center, New York, New York, United States
| | - Severin Daum
- Charite-University Medicine Berlin, Berlin, Germany
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Fernández-Bañares F, Accarino A, Balboa A, Domènech E, Esteve M, Garcia-Planella E, Guardiola J, Molero X, Rodríguez-Luna A, Ruiz-Cerulla A, Santos J, Vaquero E. Diarrea crónica: definición, clasificación y diagnóstico. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:535-59. [DOI: 10.1016/j.gastrohep.2015.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 09/21/2015] [Accepted: 09/30/2015] [Indexed: 12/16/2022]
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Woodward J. Improving outcomes of refractory celiac disease - current and emerging treatment strategies. Clin Exp Gastroenterol 2016; 9:225-36. [PMID: 27536154 PMCID: PMC4976763 DOI: 10.2147/ceg.s87200] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Intestinal inflammation and symptoms of celiac disease (CD) usually respond well to gluten withdrawal, but rare cases are refractory to diet. Two types of refractory CD are discriminated on the basis of the presence or absence of an atypical population of mucosal lymphocytes that may progress to enteropathy-associated T-cell lymphoma. Challenges remain in the secure diagnosis of both types of refractory disease, and evidence on which to base treatment recommendations is flawed by the small numbers of reported patients and the use of different diagnostic strategies. Recent advances in our understanding of the mechanisms of the condition in conjunction with the development of immunomodulatory agents for managing other inflammatory diseases are helping to shape future approaches to targeted therapy. Progression will depend on collaboration and recruitment to trials. In the meantime, there is evidence to suggest that earlier diagnosis and better follow-up and management of CD may prevent the development of refractoriness.
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Affiliation(s)
- Jeremy Woodward
- Department of Gastroenterology and Clinical Nutrition, Addenbrooke’s Hospital, Cambridge, UK
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25
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Talayero P, Mancebo E, Calvo-Pulido J, Rodríguez-Muñoz S, Bernardo I, Laguna-Goya R, Cano-Romero FL, García-Sesma A, Loinaz C, Jiménez C, Justo I, Paz-Artal E. Innate Lymphoid Cells Groups 1 and 3 in the Epithelial Compartment of Functional Human Intestinal Allografts. Am J Transplant 2016; 16:72-82. [PMID: 26317573 DOI: 10.1111/ajt.13435] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 05/27/2015] [Accepted: 06/21/2015] [Indexed: 01/25/2023]
Abstract
We examined intraepithelial lymphocytes (IELs) in 213 ileal biopsies from 16 bowel grafts and compared them with 32 biopsies from native intestines. During the first year posttransplantation, grafts exhibited low levels of IELs (percentage of CD103(+) cells) principally due to reduced CD3(+) CD8(+) cells, while CD103(+) CD3(-) cell numbers became significantly higher. Changes in IEL subsets did not correlate with histology results, isolated intestine, or multivisceral transplants, but CD3(-) IELs were significantly higher in patients receiving corticosteroids. Compared with controls, more CD3(-) IELs of the grafts expressed CD56, NKp44, interleukin (IL)-23 receptor, retinoid-related orphan receptor gamma t (RORγt), and CCR6. No difference was observed in granzyme B, and CD3(-) CD127(+) cells were more abundant in native intestines. Ex vivo, and after in vitro activation, CD3(-) IELs in grafts produced significantly more interferon (IFN)-γ and IL-22, and a double IFNγ(+) IL-22(+) population was observed. Epithelial cell-depleted grafts IELs were cytotoxic, whereas this was not observed in controls. In conclusion, different from native intestines, a CD3(-) IEL subset predominates in grafts, showing features of natural killer cells and intraepithelial ILC1 (CD56(+) , NKp44(+) , CCR6(+) , CD127(-) , cytotoxicity, and IFNγ secretion), ILC3 (CD56(+) , NKp44(+) , IL-23R(+) , CCR6(+) , RORγt(+) , and IL-22 secretion), and intermediate ILC1-ILC3 phenotypes (IFNγ(+) IL-22(+) ). Viability of intestinal grafts may depend on the balance among proinflammatory and homeostatic roles of ILC subsets.
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Affiliation(s)
- P Talayero
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain
| | - E Mancebo
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain
| | - J Calvo-Pulido
- Department of General and Digestive Surgery and Abdominal Organ Transplantation, University Hospital 12 de Octubre, Madrid, Spain
| | - S Rodríguez-Muñoz
- Department of Gastroenterology, University Hospital 12 de Octubre, Madrid, Spain
| | - I Bernardo
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain
| | - R Laguna-Goya
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain
| | - F L Cano-Romero
- I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain
| | - A García-Sesma
- Department of General and Digestive Surgery and Abdominal Organ Transplantation, University Hospital 12 de Octubre, Madrid, Spain
| | - C Loinaz
- Department of General and Digestive Surgery and Abdominal Organ Transplantation, University Hospital 12 de Octubre, Madrid, Spain
| | - C Jiménez
- I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain.,Department of General and Digestive Surgery and Abdominal Organ Transplantation, University Hospital 12 de Octubre, Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain
| | - I Justo
- Department of General and Digestive Surgery and Abdominal Organ Transplantation, University Hospital 12 de Octubre, Madrid, Spain
| | - E Paz-Artal
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain.,I+12 Research Institute, University Hospital 12 de Octubre, Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain.,Section of Immunology, San Pablo CEU University, Madrid, Spain
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van Wanrooij RLJ, Müller DMJ, Neefjes-Borst EA, Meijer J, Koudstaal LG, Heideman DAM, Bontkes HJ, von Blomberg BME, Bouma G, Mulder CJJ. Optimal strategies to identify aberrant intra-epithelial lymphocytes in refractory coeliac disease. J Clin Immunol 2014; 34:828-35. [PMID: 25062848 DOI: 10.1007/s10875-014-0075-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 07/02/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Different strategies have been developed to identify those refractory celiac disease (RCD) patients who are at risk to develop an enteropathy associated T-cell lymphoma (EATL). Flow cytometric analysis of intra-epithelial lymphocytes (IEL) with an aberrant phenotype is considered the golden standard but is not widely available. Immunohistochemistry (IHC) and T-cell receptor (TCR) rearrangement studies are commonly available but may lack sensitivity and specificity. Here, we compared the three different methods in the workup of patients suspected for RCD. METHODS Duodenal biopsies from control patient (n = 5), RCD patients with moderately increased aberrant IEL populations (20-50 %: n = 14), and RCD patients with high numbers of aberrant IEL (>50 %: n = 5) as determined by flow cytometry were analysed by IHC and TCR-γ chain rearrangement analysis. Three pathologists scored the slides independently. RESULTS Sensitivity of IHC and TCR-γ rearrangement analysis in RCD patients with high numbers of aberrant IELs was 100 and 71 %, respectively. RCD patients with aberrant cells between 25 and 50 % however, were missed by IHC and TCR in 50 and 57 % of cases, respectively. In addition, inter-rater reliability analysis of the IHC scoring revealed coder-pair Kappa coefficients between 0.28 and 0.85. CONCLUSION Immunohistochemistry and to a lesser extent TCR-γ clonality analysis are sensitive in identifying patients with high numbers of aberrant IEL populations, yet miss half of RCD patients with moderately increased numbers. In addition, IHC has a high inter-observer variability. Therefore, patients suspected for RCD should undergo flow cytometric analysis of the duodenum.
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Affiliation(s)
- R L J van Wanrooij
- Department of Gastroenterology and Hepatology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands,
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Liu H, Fofaria RK, Greenfield SM, Robson A, Wright P, Isaacson PG, Woodward J, Du MQ. The aberrant intraepithelial T cells in refractory coeliac disease show epidermotropism. J Clin Pathol 2014; 67:380-2. [PMID: 24403188 DOI: 10.1136/jclinpath-2013-202066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Hongxiang Liu
- Department of Histopathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, , Cambridge, UK
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Abstract
Celiac disease (CD) is an immune-mediated systemic condition triggered by dietary gluten occurring in genetically susceptible individuals. Our understanding of its numerous and varied clinical presentations has evolved over time, which has contributed to the incidence of CD increasing. In most cases, the diagnosis is readily established and patients promptly improve after commencing a gluten-free diet (GFD). However, in some, the diagnosis is not straightforward and presents a challenge to clinicians. Potential dilemmas include those with positive serology but normal histology, negative serology but abnormal duodenal mucosal histology, failure to respond to a GFD or response to a GFD without evidence of CD. In recent years, development of new assays and modifications to existing diagnostic algorithms for CD has also challenged the traditional role of small-bowel histology as critical in CD diagnosis.
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Affiliation(s)
- Michael X Ma
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, WA 6001, Australia
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Abstract
A significant proportion of patients with coeliac disease are 'nonresponsive' to gluten withdrawal. Most cases of nonresponsive coeliac disease are due to persisting gluten ingestion. Refractory coeliac disease (RCD) is currently defined by persistent symptoms and signs of malabsorption after gluten exclusion for 12 months with ongoing intestinal villous atrophy. Primary (without initial response to diet) and secondary (relapse following response to diet) RCD is recognized. RCD is further classified as type I or type II based on the absence or presence of a population of aberrant intestinal lymphocytes. Quality of dietetic advice and support is fundamental, and lack of objective corroboration of gluten exclusion may result in over-identification of RCD I, particularly in those cases with persisting antibody responses. Over-reliance on lymphocyte clonality similarly may result in over-diagnosis of RCD II which requires careful quantification of aberrant lymphocyte populations. Management of RCD should be undertaken in specialist centres. It requires initial intensive dietary supervision, strict gluten exclusion and subsequent re-evaluation. There is currently insufficient evidence to recommend specific treatments. Steroids are often used in both RCD I and II (albeit with little objective evidence of benefit in RCD II), and azathioprine as steroid-sparing therapy in RCD I. There is growing evidence for the use of cladribine in RCD II with autologous stem cell transplantation in nonresponders, but this requires further multicentre evaluation. There remains considerable controversy regarding the diagnosis, treatment and surveillance of RCD: international consensus in these areas is urgently required to facilitate future therapeutic advances.
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Affiliation(s)
- Jeremy Woodward
- Consultant Gastroenterologist, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
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Chromosomal aberrations in peripheral blood lymphocytes in patients with newly diagnosed celiac and Crohn's disease. Eur J Gastroenterol Hepatol 2013; 25:22-7. [PMID: 23022983 DOI: 10.1097/meg.0b013e328359526c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aims of this research were to determine the number of chromosomal aberrations in peripheral blood lymphocytes and to evaluate the number of circulating lymphocytes with CD103, integrin expressed on intraepithelial lymphocytes and preserved in enteropathy-associated T-cell lymphoma, in patients with newly diagnosed Crohn's disease, celiac disease, and healthy controls. METHODS During the period of 30 months, we included 44 patients. Chromosome aberrations were analyzed in peripheral blood lymphocytes by a single cytogeneticist. Multicolor flow cytometric was used for immunophenotyping of peripheral blood lymphocytes. RESULTS We found a significantly higher number of chromosomal aberrations/100 metaphases in the celiac and Crohn's disease group compared with the controls (P=0.01) and they also had a significantly higher number of aberrant cells compared with the controls (P<0.001). There was no statistically significant difference between the groups with respect to the percentage of CD103+ and CD8+CD103+ cells between groups (P=0.16 and 0.41, respectively) and no correlation between the total number of chromosomal aberrations and the percentage of CD103+ and CD8+CD103+ cells (P=0.06 and 0.06, respectively). CONCLUSION Patients with active celiac and newly diagnosed Crohn's disease, before treatment initiation, have a significantly increased number of chromosomal aberrations in peripheral blood lymphocytes. No dissemination of intraepithelial cells in the blood and correlation to the chromosomal aberration was found.
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Busto Bea V, Crespo Pérez L, Rodríguez-Gandía MÁ, Roy Ariño G, García-Miralles N, Cano Ruiz A. [Enteropathy-associated T-cell lymphoma: a diagnostic challenge]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:686-9. [PMID: 22112633 DOI: 10.1016/j.gastrohep.2011.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Revised: 07/26/2011] [Accepted: 08/04/2011] [Indexed: 01/27/2023]
Abstract
Diagnosis of refractory celiac disease (CD) is based on exclusion of other disorders, persistence of malabsorptive symptoms and villous atrophy, despite a strict gluten-free diet for at least 6-12 months. Detection of alterations in the intraepithelial lymphocyte population is crucial for diagnosis. A subgroup of patients with refractory CD may develop severe complications such as enteropathy-associated T cell lymphoma (EATL). We present the case of a patient with longstanding silent CD who developed EALT, highlighting the challenge posed by the diagnosis and treatment of this entity.
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Affiliation(s)
- Victoria Busto Bea
- Servicio de Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, España.
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Burke JS. Lymphoproliferative disorders of the gastrointestinal tract: a review and pragmatic guide to diagnosis. Arch Pathol Lab Med 2011; 135:1283-97. [PMID: 21970484 DOI: 10.5858/arpa.2011-0145-ra] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT The gastrointestinal tract is the most common site of extranodal lymphomas. Although all histologic categories of malignant lymphoma develop in the gastrointestinal tract, large B-cell lymphomas predominate, followed by extranodal marginal zone lymphomas of mucosa-associated lymphoid tissue (MALT) type; the latter is especially prevalent in stomach. The acceptance of extranodal marginal zone lymphoma of MALT type as a clinicopathologic entity has reduced the number of cases that formerly were interpreted as florid lymphoid hyperplasia ("pseudolymphoma"). Nonetheless, the distinction of lymphoid hyperplasia from a lymphoma of MALT type in small biopsy specimens remains problematic. OBJECTIVE To assess the relevant morphologic, immunologic, molecular, and genetic properties of gastrointestinal lymphomas and to present a feasible tactic for diagnosis, expressly for small biopsy specimens. DATA SOURCES Case-derived material and literature review using PubMed (National Library of Medicine). CONCLUSIONS Most gastrointestinal lymphomas are readily amenable to an unqualified diagnosis, primarily those cases consisting of monomorphic large cells whether of B- or T-cell lineage, including cases associated with enteropathy. Diagnosis for infiltrates dominated by small lymphocytes remains taxing, as the differential diagnosis embraces not only MALT lymphoma and lymphoid hyperplasia but also mantle cell lymphoma, follicular lymphoma, and chronic lymphocytic leukemia/small lymphocytic lymphoma. Adherence to strict morphologic criteria is the standard for diagnosis, but these criteria should be augmented by immunologic studies together with judicious use of molecular techniques to determine clonality. In establishing a diagnosis of gastric marginal zone lymphoma of MALT type, determination of t(11;18)(q21;q21) status may be required since this translocation has clinical ramifications.
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Affiliation(s)
- Jerome S Burke
- Department of Pathology, Alta Bates Summit Medical Center, Berkeley, California 94705, USA.
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Abstract
PURPOSE OF REVIEW To critically summarize recent research in celiac disease. RECENT FINDINGS There are new serological markers with potential use not only in the diagnosis of celiac disease but also as important follow-up tools. As our understanding of celiac disease increases with further isolation of nonhuman leukocyte antigen genes and clarification of the intracellular pathways that underlie its pathogenesis, there are new modalities which will not only allow improved risk stratification of individuals but also facilitate the development of novel therapeutic agents. SUMMARY Small bowel biopsy remains the gold standard for both diagnosis and monitoring. A gluten-free diet currently remains the only treatment option, with potential other options being discovered such as glutenases for predigestion of gluten.
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Rubio-Tapia A, Barton SH, Murray JA. Celiac disease and persistent symptoms. Clin Gastroenterol Hepatol 2011; 9:13-7; quiz e8. [PMID: 20692372 PMCID: PMC3037763 DOI: 10.1016/j.cgh.2010.07.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Revised: 07/12/2010] [Accepted: 07/18/2010] [Indexed: 02/07/2023]
Affiliation(s)
- Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Abstract
Coeliac disease is increasing in prevalence, which is currently estimated at one in 100 of the population and may occur de novo in adults. The diagnosis requires a joint clinicopathological approach; the recommended first-line test is serology with immunoglobulin A (IgA) tissue transglutaminase and IgA endomysial antibodies. These serological tests show high levels of sensitivity and specificity, but biopsy is the gold standard to confirm the diagnosis. It is important that both tests are performed before the introduction of a gluten-free diet. Although the classical histopathology changes of coeliac disease with partial or total villous atrophy are well recognized, the pathology classification of coeliac disease is changing, with recognition that coeliac disease may show minimal pathology (normal architecture and an intraepithelial lymphocyte count/100 enterocytes ≥ 25). This entity is also described as lymphocytic duodenosis, and recommendation of follow-up serology testing is paramount in this condition. Follow-up of patients with coeliac disease is warranted, as normal serology does not predict mucosal recovery. Failure to heal predicts risk of progression to refractory coeliac disease and malignancies. Refractory coeliac disease occurs in 1-2% of patients and this diagnosis requires a combined clinical and histopathology approach with immunocytochemistry.
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Affiliation(s)
- Marjorie M Walker
- Department of Histopathology, Imperial College London, St. Mary's Hospital, London, UK.
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Leon F. Flow cytometry of intestinal intraepithelial lymphocytes in celiac disease. J Immunol Methods 2010; 363:177-86. [PMID: 20833175 DOI: 10.1016/j.jim.2010.09.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Revised: 08/21/2010] [Accepted: 09/01/2010] [Indexed: 01/04/2023]
Abstract
This article reviews the multiple uses of flow cytometry in the diagnosis, monitoring and research of celiac disease, the most prevalent chronic autoimmune gastrointestinal disease. The phenotyping of intraepithelial lymphocytes (IELs) is of clinical relevance in the diagnosis of the disease given the characteristic features of elevated CD3+ IELs (αβ and γδ TcR) and the decrease in CD3- IELs. IEL biomarkers are also useful in the assessment of the response to the gluten-free diet and, importantly, in the diagnosis of the severe complications of celiac disease: refractory celiac disease and enteropathy-associated T-cell lymphoma. Novel applications of flow cytometry for the detection of anti-transglutaminase antibodies (a validated biomarker of celiac disease) and of gluten (the triggering antigen of the autoimmune process) are also discussed. The assessment of diagnostic and prognostic biomarkers by flow cytometry in celiac disease is performed routinely in a growing number of centers and it is an example of the versatility of this technique and its applicability to the research and clinical study of solid tissues.
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Affiliation(s)
- Francisco Leon
- Clinical Development, Alba Therapeutics, 800 W. Baltimore St, Suite 400, Baltimore, MD 21201, USA.
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