The Oslo definitions for coeliac disease and related terms

New therapies in celiac disease

PURPOSE OF REVIEW

Celiac disease (CeD) is a chronic autoimmune disorder of the small intestine triggered by gluten ingestion in genetically predisposed individuals. The cornerstone of CeD management remains a strict adherence to a lifelong gluten-free diet (GFD), although such a dietary restriction can lead to an altered quality of life and may not be easy to follow for many patients. These challenges highlighted the need for alternative therapies. This review aims to explore the latest advancements in these therapeutic avenues, emphasizing mechanisms of action, clinical efficacy, and safety profiles of drugs currently in advanced stages of clinical testing.

RECENT FINDINGS

Recent advances in the understanding of CeD pathophysiology have catalyzed the development of new therapeutic approaches, which include strategies to modify gluten processing in the gut, block gluten-triggered immune responses, or restore immune tolerance to gluten.

SUMMARY

While these therapies are not poised to take the place of GFD, they represent promising treatment alternatives that could enhance the quality of life and minimize long-term consequences in CeD patients. Further research, as well as phase III clinical trials of those already conducted, are needed to establish the feasibility of integrating these novel drugs in the clinical management of CeD.

ICD-10-CM coding uncovers the gap between serological and clinically identified coeliac disease prevalence: A population-based study

BACKGROUND

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is a global health coding system that provides a standardised language for recording, reporting and monitoring diseases. However, epidemiological studies using real-world data on clinically diagnosed coeliac disease (CD) based on the ICD-10-CM remain limited.

AIMS

To evaluate in primary care: (1) the diagnostic adequacy of CD; (2) the accuracy of the ICD-10-CM code K90.0 for identifying CD; and (3) the prevalence of clinically diagnosed CD compared with the known CD seroprevalence in the same geographical area (5‰).

METHODS

This was a population-based, cross-sectional study in the city of L'Hospitalet de Llobregat (269,382 inhabitants), Catalonia, from 2005 to 2020. The data retrieved with the K90.0 code from electronic medical records were cross-checked against laboratory and pathology registries. The CD diagnostic criteria were validated on a case-by-case basis. To calculate the accuracy of the K90.0 code for identifying CD, patients were classified into confirmed versus uncertain/misdiagnosed CD.

RESULTS

Overall, 536/737 patients (73 %) had confirmed CD, and 201/737 (27 %) were misdiagnosed. The accuracy of the K90.0 code for identifying CD was as follows: sensitivity, 91.63 %; specificity, 99.95 %; positive predictive value, 63.85 %; and negative predictive value, 99.99 %. The prevalence of clinically diagnosed CD was 1.99‰, with a decreasing age-related trend of -7.5 %.

CONCLUSIONS

The ICD-10-CM code K90.0 is accurate for identifying clinically diagnosed CD and is thus a great tool for epidemiological disease surveillance. The gap between CD seroprevalence and the prevalence of clinically diagnosed CD (5‰ vs. 1.99‰) calls for the implementation of case-finding programmes to reduce underdiagnosis.

Clinical settings in which human leukocyte antigen typing is still useful in the diagnosis of celiac disease

Celiac disease (CD) is a systemic autoimmune disorder triggered by gluten ingestion ingenetically predisposed individuals. It is characterized by intestinal histological damage and the production of specific autoantibodies. The latest European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2020 guidelines have excluded human leukocyte antigen (HLA) genotyping from the no-biopsy diagnostic approach due to its weak positive predictive value, limited availability, and high cost in some countries. However, HLA genetic testing remains valuable in certain clinical contexts. This study provided practical indications for when to request and how to interpret HLA genotyping, emphasizing its continued relevance for CD diagnosis in specific cases. We also proposed a strategy for monitoring the risk of developing type 1 diabetes (T1D) in patients with CD, based on the risk stratification carried by different HLA genotypes. A retrospective analysis of 746 patients with CD and 627 controls was conducted at our hospital starting in 2012, when HLA genotyping became mandatory for the diagnosis of CD. We identified key clinical scenarios where HLA testing remains useful. Several high risk HLA-DQ genotypes strongly associated with CD were highlighted, including HLA-DQ2.5/HLA-DQ2.2 and HLA-DQ2.5/HLA-DQ2.5. Notably, while the HLA-DQ2.5/HLA-DQ2.2 genotype is linked to CD, it appears to confer protection against T1D. To support clinical practice, we presented a table clarifying commonly used HLA terminology, and another summarized the main clinical situations in which HLA genotyping should still be considered. These findings underscore the dual role of HLA testing: Not only can it help rule out CD in selected cases, but it also identifies patients with CD at risk for T1D, guiding personalized monitoring strategies.

Mild Duodenal Mucosal Injury and Increased Type I Interferon Signaling are Preludes to Celiac Disease

Celiac disease (CeD) is an immune-mediated chronic enteropathy caused by gluten exposure in genetically susceptible individuals. The characteristic histologic features of CeD include increased intraepithelial lymphocytes (IELs) and villous atrophy. Clinically, a subset of individuals with elevated concentrations of serum tissue transglutaminase (TTG) antibodies have intact duodenal villous architecture at initial endoscopy and biopsy but then progress to CeD over time while on gluten-containing foods. We hypothesize that these rare potential CeD cases with progression can allow us to interrogate histologic and molecular signatures to predict those who subsequently develop CeD, and to study the final cascade into the overt lesions of CeD. We retrospectively identified 16 children over a 10-year period with elevated serum TTG antibody concentrations but without significant villous atrophy at index duodenal biopsies, in whom subsequent biopsies confirmed CeD while consuming gluten-containing foods. Their clinical and histologic features were compared with age-, race-, and gender-matched controls including active CeD (n=28) and non-CeD children (negative TTG antibody, normal histology, n=35). Transcriptomic analysis was performed on a subset of the index biopsies of potential CeD cases with progression and controls. None of the 16 potential CeD children with progression had a family history of CeD or presented with poor growth or anemia or had commenced a gluten-free diet at the time of index biopsy. The index biopsies of potential CeD children with progression had significantly greater prevalence of IELs (81% versus 12%, p=0.002) and mild villous atrophy (94% versus 22%, p=0.006) compared to non-CeD biopsies; none had severe villous atrophy (p=0.002). Transcriptomic analysis demonstrated upregulated type I interferon (IFN) signaling, JAK/STAT activation, and innate and adaptive immunity in duodenum of potential CeD with progression compared to non-CeD but preserved signaling in brush border absorption, transporter functions, and epithelial metabolic functions, compared to active CeD. Our results show for the first time that mild mucosal injury in the duodenum of potential CeD children with progression is accompanied by upregulation of pathways also activated in CeD. Mild mucosal injury and type I IFN signaling may be the initiating cellular and molecular biomarkers in identifying the subset of potential CeD individuals who would progress to CeD while consuming gluten-containing foods.

Celiac disease screening in children: evaluating the evidence, benefits, and challenges

Comprehensive screening of the general population is the only approach capable of identifying the majority of cases with celiac disease. In 2023, the Italian Parliament enacted a law to implement nationwide screening for celiac disease and type 1 diabetes. However, critical decisions regarding the target population, optimal timing, and screening methods remain unresolved. Previous observational studies on birth cohorts of children with genetic risk for these conditions have demonstrated that the incidence peaks early in life and is influenced by HLA risk genotypes. This mini-review explores different aspects of screening for celiac disease, presenting the advantages and challenges of identifying children before onset of symptoms. In addition, we summarize the current knowledge and gaps in understanding related to screening programs for celiac disease in children and adolescents and discuss health benefits, psychosocial aspects and cost-effectiveness, and their potential implications for future public health strategies.

A new histomorphological finding in the follow-up of celiac disease: Intraepithelial lymphocyte localization is a reliable indicator of dietary compliance

The correlation between clinical, serological, and endoscopic findings and histological response after a gluten-free diet (GFD) is limited in adult celiac (CD) patients. This study aims to evaluate the effects of GFD on intraepithelial lymphocyte (IEL) localization by comparing the histopathological, clinical, serological, and endoscopic findings of adult CD patients. The patients (n = 131) were divided into three groups: those with good (CDgc) (n = 23) and poor (CDpc) (n = 21) GFD compliance and newly diagnosed ones (nCD) (n = 87). Total and supranuclear IELs were counted per 100 enterocytes and divided into three groups: apical, mixed, and basal, according to ROC (Receiver operating characteristic) analysis. The roles of clinicopathological parameters in predicting good dietary compliance were calculated using the multivariable logistic regression model. CDgc group predominantly (78.3 %) exhibited a basal pattern, and none exhibited an apical. Conversely, most CDpc and nCD patients showed mixed (66.7 % and 73.6 %, respectively) and apical (9.5 % and 25.3 %) patterns. Non-atrophic Marsh types (p = 0.040) and basal pattern (p = 0.043) were independent parameters predicting good dietary compliance. This study first showed that IEL localizations can indicate GFD compliance in samples from CD patients. Localization-based examination of IELs can be an additional histological indicator in monitoring GFD compliance and signs of recovery, especially in adult CD patients.

Exploring Challenges Faced by Adults Living With Celiac Disease: A Food Literacy Perspective

BACKGROUND

Coeliac disease (CD) is an autoimmune disorder treated with a gluten-free diet (GFD), requiring substantial changes in food choices and eating habits. This study explores the challenges faced by adults living with CD focusing on the theme of food literacy (FL), namely functional, relational, and system FL competencies.

METHODOLOGY

A secondary analysis of data obtained through an online questionnaire was conducted. Adults living with CD in Québec, Canada and subscribed to Coeliaque Québec's newsletter were invited to complete a questionnaire. Using the critical incident method, respondents described a negative experience in their journey living with CD. Content analysis was done in a deductive and inductive manner, based on the 2022 Slater Food Literacy framework adapted to CD.

RESULTS

A total of 743 patients were included in the analysis. The qualitative analysis resulted in 11 codes under the three themes of FL. Patients reported challenges in finding reliable nutrition and medical information, managing a GFD in social settings, explaining CD and preventing gluten contamination, preparing balanced gluten-free (GF) meals, and making informed food choices. Patients reported on the negative impact of the GFD on their relationship with food, and how CD inhibits conviviality. Finally, patients addressed the need to advocate for GF food access in grocery stores and restaurants.

CONCLUSIONS

This study highlights the broad impacts of effectively managing CD and the GFD on patients' functional, relational and system FL competencies. Future research should explore how social and economic factors further interact with FL competencies of adults living with CD.

What is new in the management of coeliac disease?

Coeliac disease is the most common immune-mediated enteropathy, affecting approximately 1 % of the population worldwide. Currently, the vast majority of individuals remain undiagnosed. Coeliac disease is triggered by gluten ingestion in genetically predisposed individuals carrying the human leukocyte antigen (HLA) genes; HLA-DQ2 and HLA-DQ8. Patients with coeliac disease present with a wide spectrum of gastrointestinal and extraintestinal manifestations and, in some cases, without any symptoms. The diagnosis of coeliac disease in adults is based on a combination of clinical suspicion, positive serological markers and histological evidence of small intestinal atrophy on duodenal biopsies. The only effective treatment is a strict, lifelong gluten-free diet. However, up to 20 % of patients report persistent or recurrent symptoms. In this review, we provide a comprehensive update on coeliac disease, focusing on its relevance to the different medical specialities and highlighting the need for a multidisciplinary approach to its diagnosis and management. Clinicians practicing internal medicine have a unique opportunity to diagnose this multisystem autoimmune disease. By doing so, they would avoid delays in diagnosis for these patients. A low threshold for serological testing is recommended.

A Meta-Synthesis Exploring Daily Experiences of Adults With Coeliac Disease in Adhering to a Gluten-Free Diet

BACKGROUND

Coeliac disease (CD) is an autoimmune disease affecting 1.4% of the population worldwide. The only treatment for this condition is a strict, lifelong gluten-free diet (GFD). Although the complexity of this condition is recognised, the definitive follow-up strategy and long-term management have still not been developed in the United Kingdom (UK) and Australia. This meta-synthesis aimed to explore the experiences of patients living with CD who follow the GFD in the UK and Australia.

METHODS

A systematic search for primary qualitative literature related to experiences of patients with CD on a GFD and a meta-synthesis of the results were conducted. Healthcare-relevant online databases were screened: Academic Search Complete, CINAHL, MEDLINE, and Scopus, followed by reference list searching. A defined inclusion criteria were used to identify relevant studies. The data synthesis from the literature followed the thematic synthesis approach. A clear description of the methodology and peer review were applied to ensure transparency.

RESULTS

A total of 286 studies were screened for eligibility. Of those, six studies met the inclusion criteria. The experiences of 198 patients living with CD were analysed and reported. Five analytical themes emerged through the thematic synthesis process: acceptance and adaptation, dietary burden, cost burden, socialising, and importance of support. All themes were found to impact patients' quality of life (QoL). The overall quality of the reviewed studies was described as good.

CONCLUSION

This meta-synthesis revealed insights into the daily experiences of patients with CD in adhering to a GFD in the UK and Australia, being the first secondary qualitative study to explore this phenomenon. It highlighted the need for the development of defined strategies for patient follow-up to provide holistic care, considering the complexities of this condition and its impact on both physical and psychological domains.

Coeliac disease: complications and comorbidities

Coeliac disease is an autoimmune disease characterized by small intestinal villus atrophy and inflammation upon exposure to gluten. It has a global prevalence of approximately 1%. Although the gluten-free diet can be an effective treatment, this diet is burdensome with practical difficulties and frequent inadvertent gluten exposure. Moreover, there are a variety of potential complications and comorbidities of coeliac disease that might be related to malabsorption and/or chronic immune activation. Overall, individuals with coeliac disease have increased mortality compared with the general population, underscoring the severity of this common disease. Comorbidities and complications that have been associated with coeliac disease include poor growth, reproductive complications, kidney and liver diseases, respiratory disease (such as pneumonia) and infections (including sepsis). Furthermore, coeliac disease has been linked to other autoimmune disease and psychiatric disease, as well as certain cancers. Data suggest that mucosal healing on a gluten-free diet might protect against some, but not all, of these complications. In this Review, we present absolute and relative risks of coeliac-associated disorders. We discuss underlying mechanisms, the role of the gluten-free diet and mucosal healing, as well as implications for follow-up and non-dietary treatment of coeliac disease.

Elucidating Immune Cell Changes in Celiac Disease: Revealing New Insights from Spectral Flow Cytometry

Celiac disease (CD) is an immune-mediated enteropathy of the small intestine triggered by gluten ingestion. Although the small bowel is the main organ affected, peripheral blood cell alterations have also been described in CD. We aimed to investigate immunological cell patterns in the blood of treated CD patients and in response to a 3-day gluten challenge (GC). Blood samples were collected from 10 patients with CD and 8 healthy controls on a gluten-free diet at baseline and 6 days after initiating the GC. All the samples were analyzed by spectral flow cytometry using a 34-marker panel. We found that patients with CD displayed a lower proportion of memory B cells compared to healthy controls, both at baseline and post-GC. Additionally, we observed the previously reported activated gut-homing CD4+, CD8+, and TCRγδ+ T lymphocytes on day 6 post-GC, and found the CD8+ subpopulation to be the most readily identifiable by flow cytometry. Importantly, the CCR9 marker proved effective in enhancing the selection of these gluten-responsive T cells, offering the potential for increased diagnostic accuracy. Spectral flow cytometry involves a complex data analysis, but it offers valuable insights into previously unexplored immunological responses and enables in-depth cell characterization.

Hub-and-Spoke regional system supported by telehealth for managing coeliac disease in Liguria: a mixed-methods survey followed by an observational pilot study

BACKGROUND

Due to the need to reorganize the care network for the national screening mandated by law, a new healthcare model was required for the management of coeliac disease. The hub-and-spoke model is a new healthcare organizational system, here we describe its application (supported by telehealth), in the management of pediatric coeliac disease (CD) in Liguria. The results of the pilot phase are presented and the system's strengths and weaknesses discussed.

METHODS

A mixed-methods survey followed by an observational pilot study was performed. A multiphase approach was used including preparation setting, operative planning and application. The pilot phase involves a single primary center. The reduction of families' expenditure and environmental impact was assessed using the Viamichelin calculator.

RESULTS

A regional meeting followed by a survey (specifically developed for this study) and a needs analysis highlighted the priority to have an efficient, up to date and homogeneous model of care assistance throughout the network. A diagnostic and therapeutic care pathway (PDTC) was developed by the regional working group. The project involved 986 Ligurian families and allowed a 90% reduction in the distance traveled by families residing within the pilot center's catchment area, saving €177 and 113 kg of CO2 on average per family per year.

CONCLUSIONS

The Gaslini Diffuso hub-and-spoke system for managing CD in Liguria exemplifies a commitment to enhancing healthcare efficiency and patient care, reducing environmental impact and cost for both family and healthcare system.

Differential immune responses behind different celiac disease manifestations

In celiac disease (CeD), dietary gluten serves as the driver for a comparatively well characterized small bowel mucosal immune response that generally results in small bowel mucosal villous atrophy and crypt hyperplasia along with a disease-specific transglutaminase 2 (TG2) targeting autoantibody response. Individuals with positive TG2 autoantibodies but normal small intestinal mucosal morphology are regarded at increased risk of developing CeD and represent patients with potential CeD. The removal of gluten from the diet leads to disappearance of the autoantibodies and normalization of the mucosal architecture in most cases. However, refractory CeD patients deviate from this dogma as they present with abnormal T cell compartment, persistent symptoms and villous atrophy despite a strict gluten-free diet. The heterogeneity of CeD presentation is further diversified by varying symptomatology. Gastrointestinal symptoms are the most canonical signs of CeD, and they include for instance diarrhea, vomiting, constipation and abdominal pain. Yet, a great portion of the patients manifest the disease at extraintestinal sites such as skin, musculoskeletal system or neuronal tissues. Beyond the involvement of various transglutaminase autoantibodies, the detailed immune mechanisms contributing to the development of these manifestations remains elusive, though. This review highlights the current understanding of the immunological differences in various manifestations of CeD. As the immunological basis of the different CeD phenotypes is at present insufficiently understood, more research on the subject is warranted before such data could be maximally applied to clinical practice.

Celiac Disease-Narrative Review on Progress in Celiac Disease

Celiac disease is defined as a systemic immunological disorder caused by gluten (gliadin and other prolamin) in genetically predisposed individuals, who present with a variety of gluten-dependent symptoms, specific antibodies, the presence of the HLA DQ2 and DQ8 histocompatibility antigen, and enteropathy. Its prevalence, depending on the studied population and methodology, is estimated at 0.75-1.6% of the general population. During the complex immune reaction it induces, most cells involved in inflammatory processes are activated, which leads to the gradual atrophy of intestinal villi and the proliferation of enterocytes within intestinal crypts. The pathogenesis of celiac disease is extremely complicated and is still the subject of research. According to the current diagnostic guidelines, the following criteria should be taken into account: clinical symptoms (intestinal and extraintestinal), the presence of antibodies against tissue transglutaminase in the IgA class, the level of total IgA, and the presence of typical histological changes in duodenal biopsies. Diet-resistant celiac disease is one of the most important clinical challenges, causing serious complications. Currently, the basic method for treating celiac disease is an elimination diet (i.e., the exclusion of products that may contain gluten from the diet), however, new therapeutic strategies are still being sought, mainly based on supplementation with exogenous endopeptidases, modification of the immune response, and the use of zonulin inhibitors and transglutaminase 2 inhibitors. Clinical trials of new drugs are ongoing. The gradually expanding knowledge about the pathogenesis of celiac disease may allow for the development of new therapeutic strategies for both patients with a mild disease course, as well as those that are diet-resistant.

Persistence of anemia in patients with Celiac disease despite a gluten free diet: a retrospective study

BACKGROUND

The main treatment for Celiac Disease (CD) is the gluten-free diet (GFD). However, in some CD patients, iron deficiency anemia can be persistent despite a GFD.

AIM

In this study, we aim to evaluate the prevalence of anemia in both adults and children with CD at the diagnosis and during the GFD.

METHODS

In this cross-sectional study including both adults and children with CD, the demographic characteristics and hemoglobin, iron, folate and vitamin B12 levels were retrospectively retrieved from patients' medical records at the time of diagnosis (T0); after 3-5 years (T1) and after 8-10 years (T2) of GFD.

RESULTS

311 CD patients (184 adults and 127 pediatric patients) were included in the study. No difference was observed in the prevalence of anemia in the overall population after 3-5 years of GFD in both adult and pediatric patients compared to the diagnosis. At 8-10 years, in the adult patient's group, a significant reduction in the prevalence of anemia was observed (24% vs. 17.8% p = 0.043).

CONCLUSIONS

Despite the GFD and a very long observational period the diagnosis of anemia persists in 17.8% and 4.4% of adult and pediatric patients, respectively. The diagnostic delay (longer in adult patients) and a more pronounced ultrastructural mucosal injury could play a role in the persistence of anemia despite the GFD.

Unraveling the role of early coeliac disease diagnosis in the risk of developing immune-mediated renal diseases

BACKGROUND

coeliac disease (CD) is an inflammatory condition of the small intestine caused by immunological intolerance towards dietary gluten. Associations between CD and other autoimmune disorders have been extensively reported. However, the risk in CD patients of developing immune-mediated renal diseases (IMRDs) as a function of the duration of exposure to gluten remains uncharacterized.

METHODS

we used data from the Swedish national patient register to retrospectively construct two subcohorts of CD patients by either years before or after CD diagnosis, matched by sex and age to reference individuals (ratio 1:6). Adopting cox regressions, we assessed the risk in CD to develop IMRDs.

RESULTS

we found that unrecognized CD patients had a higher risk to develop the majority of the IMRDs here investigated compared with matched reference individuals. Following a CD diagnosis, the risk was reduced in eight of the twelve IMRDs. Furthermore, if patients were diagnosed with CD earlier in childhood they showed less or no increased risk to develop IMRDs compared with reference individuals. CD patients diagnosed by the age of 15 had an overall 12% increased risk of developing any IMRD, (HR: 1.12; CI = 1.02, 1.24; p < 0.02), as those with a CD diagnosis between 16 and 30 years of age had a 60% increased risk of developing IMRD (HR: 1.61; CI = 1.36, 1.91; p < 0.001).

CONCLUSIONS

Our data show that individuals diagnosed with CD at an earlier age have a lower risk of developing immune-mediated kidney conditions.

Celiac disease, non-celiac wheat sensitivity, wheat allergy - clinical and diagnostic aspects

In recent years, wheat- and gluten-free diets have increased in demand due to reported increases in various conditions reported to be driven by ingredients of these food products. Celiac disease, wheat allergy and non-celiac wheat sensitivity constitute the three main categories of wheat-related disorders. Celiac disease is a well-characterized immune-mediated disease caused by immune reaction against specific gliadin epitopes, the main protein in wheat. Screening studies of samples collected over time bring evidence that there is a true increase in prevalence not only driven by increased testing activity. Clinical presentation of CeD is diverse and there is an increased risk of autoimmune co-morbidities. Wheat allergy consists of IgE- and non-IgE-mediated reactions, driven by Th2-cells directing eosinophil and basophil responses. Rapid IgE-mediated reactions are characterized by specific IgE antibodies in conjunction with symptoms originating especially from the respiratory and gastrointestinal tract. There is an increased risk of other allergies and the majority recover during adolescence. Non-IgE-mediated wheat allergy is a less-well defined condition, which is often diagnostically challenging due to a longer interval between exposure and symptoms and lack of non-invasive biomarkers. In this condition, wheat as a trigger needs to be established by exclusion followed by dietary challenge. Non-celiac wheat sensitivity, despite being the most recently recognized, has the highest reported prevalence among the three wheat-related entities. It remains, however, particularly poorly characterized due to unclear pathophysiology and lack of diagnostic markers. This narrative review will scrutinize the shared and distinct clinical features of the three wheat-related conditions, focusing on epidemiology, clinical presentation, co-morbidities, diagnosis, treatment and prognosis.

Long-term risk of chronic liver disease in patients with celiac disease: a nationwide population-based, sibling-controlled cohort study

Background

Celiac disease (CeD) may be associated with elevated liver enzymes. However, little is known about the risk of chronic liver disease (CLD) of various etiologies or major adverse liver outcomes (MALO) in CeD. We aimed to investigate the long-term risk of CLD in patients with CeD.

Methods

Swedish nationwide cohort study. We identified 48,027 patients with biopsy-confirmed CeD between 1969 and 2017. Each patient was exactly matched with ≤5 general population reference individuals (n = 231,909) and followed through 2021. Flexible parametric survival models estimated adjusted hazard ratios (aHRs) of any and specific CLD (i.e., viral hepatitis, metabolic dysfunction-associated steatotic liver disease [MASLD], alcohol-related liver disease, and autoimmune liver disease) and MALO (compensated/decompensated cirrhosis, hepatocellular carcinoma, liver transplantation, and liver-related death).

Findings

During a median follow-up of 16.0 years, 649 patients with CeD and 1571 reference individuals developed any CLD (incidence rate: 79.4 vs. 39.5/100,000 person-years). CeD patients had a higher risk of developing any CLD than reference individuals (aHR = 2.01, 95%CI:1.82-2.22). This risk remained elevated ≥25 years after diagnosis, giving one extra CLD case per 110 CeD patients until then. Positive associations were present for autoimmune liver disease (aHR = 4.86), MASLD (aHR = 2.54), and alcohol-related liver disease (aHR = 1.51). Individuals with CeD were at significantly higher risk of incident MALO (aHR = 1.54). Sibling comparisons and sensitivity analyses confirmed the main findings.

Interpretation

CeD is associated with a persistently increased risk of any incident CLD, although the absolute risk is low. Physicians should be vigilant to early signs of liver dysfunction in patients with CeD.

Funding

European Crohn's and Colitis Organisation, the Swedish Society for Medical Research (project#: PG-23-0315-H-02), FORTE (project#: 2016-00424), Takeda, and the Swiss National Science Foundation (project#: P500PM_210866).

Serological screening for coeliac disease in an adult general population: the HUNT study

BACKGROUND

A large proportion of individuals with coeliac disease (CeD) remain undiagnosed.

OBJECTIVE

The aim of this study was to assess serological screening for CeD in the adult general population.

DESIGN

The study was based on the fourth Trøndelag Health Study, a population-based study performed 2017-2019 in Nord-Trøndelag County, Norway, including 56 042 participants >20 years of age (54% participation rate). Serum samples were analysed with a dual antitransglutaminase 2 (TG2) IgA and IgG assay and seropositive participants were invited to endoscopy with duodenal biopsies. A CeD diagnosis was given if mucosal damage (Marsh grade 3) was found.

RESULTS

Histological evaluation of 657 seropositive participants confirmed CeD in 423. The positive predictive value (PPV) of a positive TG2 IgA was 73.3% (95% CI 69.7% to 77.0%) for biopsy-confirmed CeD. TG2 IgA ≥10 times the upper limit of normal (ULN), as used in the no-biopsy approach in children, increased the PPV to 88.1% (95% CI 84.8% to 91.4%). Primary TG2 IgG response was found in 87 participants, five of whom had biopsy-confirmed CeD. One of the participants with CeD primarily responding with TG2 IgG was IgA deficient. The PPV of a positive TG2 IgG was 5.8% (95% CI 1.9% to 12.9%) and of TG2 IgG ≥10× ULN was 9.5% (95% CI 1.2% to 30.4%) for biopsy-confirmed CeD in TG2 IgA-negative individuals.

CONCLUSION

The TG2 IgA assay showed excellent abilities as a screening tool for CeD in the adult general population. However, the diagnostic accuracy of TG2 IgG was too poor for selectively identifying individuals with CeD.

Neutralizing IL-15 Inhibits Tissue-Damaging Immune Response in Ex Vivo Cultured Untreated Celiac Intestinal Mucosa

In celiac disease (CeD), interleukin 15 (IL-15) affects the epithelial barrier by acting on intraepithelial lymphocytes, promoting interferon γ (IFN-γ) production and inducing strong cytotoxic activity as well as eliciting apoptotic death of enterocytes by the Fas/Fas ligand system. This study investigates the effects of a monoclonal antibody neutralizing the effects of IL-15 (aIL-15) on tissue-damaging immune response in untreated CeD patients by using an organ culture system. Jejunal biopsies from 10 untreated CeD patients were cultured ex vivo with or without aIL-15. Epithelial expressions of CD95/Fas, HLA-E and perforin were analyzed by immunohistochemistry. Apoptosis was detected in the epithelium by using the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay. Additionally, the surface epithelium compartment of ex vivo cultured biopsy samples was isolated by laser capture microdissection (LCM). RNA from each LCM sample was extracted and the relative expression of IFN-γ was evaluated by quantitative reverse transcriptase-PCR (qRT-PCR). Biopsies cultured with the aIL-15 antibody showed a reduction in Fas, HLA-E and perforin epithelial expression, as well as a decrease in epithelial TUNEL+ cells compared to biopsies cultured without the aIL-15 antibody. Moreover, downregulation of epithelial IFN-γ expression was recorded in biopsies incubated with aIL-15, compared to those cultured without aIL-15. Our findings suggest that neutralizing the effects of IL-15 in ex vivo cultured untreated CeD intestinal mucosa could block apoptosis by downregulating Fas and HLA-E expression and the release of cytotoxic proteins, such as perforin. Furthermore, it can dampen the hyperactive immune response by reducing IFN-γ expression. More generally, our study provides new evidence for the effects of anti-IL-15 neutralizing monoclonal antibodies in preventing or repairing epithelial damage and further supports the concept that IL-15 is a meaningful therapeutic target in CeD, or inflammatory diseases associated with the upregulation of IL-15.

Utilizing both IgA tissue transglutaminase and IgG-deamidated gliadin peptide antibodies offers accurate celiac disease diagnosis without duodenal biopsy

BACKGROUND

Gastroenterologists still raise concerns about adopting a non-biopsy strategy for diagnosing celiac disease (CeD) in adults.

AIM

To assess the performance of the concurrent detection of two autoantibodies targeting two independent antigens, tissue transglutaminase (tTG) and deamidated gliadin peptides (DGP).

METHODS

This prospective, multicenter, binational study collected consecutive patients with a high pre-test probability for CeD. Between 2018 and 2020, adults were enrolled at four Italian and one Argentinian center. Serology was also blindly analyzed by a central laboratory (Werfen, San Diego, USA) for tTG IgA and DGP IgG by Aptiva Particle-based multi-analyte technology (PMAT) assays. CeD diagnosis required histological confirmation of Marsh 3 damage.

RESULTS

181 adult patients with suspected CeD were enrolled (134 with histological diagnosis of CeD and 47 not histologically confirmed as CeD). Patients positive for both tTG IgA and DGP IgG (double positive) were predictive of CeD in 92.5 % of patients at >1x upper limit of normal (ULN). Double positivity for tTG IgA and DGP IgG, both at >10x ULN, had a 100 % positive predictive value for the presence of Marsh 3 histology.

CONCLUSIONS

Incorporating DGP IgG alongside tTG IgA in a single-step approach can be considered a valid confirmatory strategy for definitive non-biopsy diagnosis of CeD.

Associations of Clinical Presentation of Coeliac Disease with Comorbidities and Complications: A Retrospective Single-Centre Analysis

Background: The clinical presentation of coeliac disease (CD) is various and may influence disease course. We aimed to investigate the associations of clinical presentation with comorbidities and disease complications in a cohort of Hungarian coeliac patients. Methods: In this retrospective study, data of consecutive CD patients were analysed. Clinical presentation (classical vs. non-classical), extraintestinal manifestations and comorbidities (anaemia, metabolic bone disease, dermatitis herpetiformis, IgA deficiency, chromosomal abnormalities, autoimmune diseases and malignancy) were assessed. Student's t-test (for age at diagnosis) and the Chi-squared test or Fisher's exact test (for categorical variables) were applied as analyses. Results: A total of 738 patients were included. In classical vs. non-classical comparisons, classical presentation was significantly associated with metabolic bone disease (59 vs. 36%, respectively, p < 0.001), anaemia (47 vs. 38%, respectively, p = 0.027) and malignancy (6 vs. 2%, respectively, p = 0.006); however, autoimmune diseases and dermatitis herpetiformis were more common with non-classical presentation (23 vs. 31%, p = 0.02, and 5 vs. 16%, p = 0.014, respectively). Conclusions: Our findings confirm that clinical presentation is associated with certain comorbidities and complications in CD. More personalised follow-up may be recommended based on clinical presentation.

Variations in the composition and frequency of celiac disease epitopes among synthetic wheat lines

Bread wheat serves as an important staple crop in the human diet, largely because of the physicochemical properties of its dough and its protein content. Gluten is the main and complex component of wheat proteins. Despite the significant importance in breadmaking properties, wheat gluten contains some immunogenic peptides capable of triggering a T cell reaction in celiac disease (CD) patients, leading to inflammation in the small intestine. Among gluten proteins, α-gliadins are the most immunogenic components because they possess the primary T-cell stimulating epitopes (DQ2.5-Glia-α1, DQ2.5-Glia-α2, and DQ2.5-Glia-α3), which are primarily located on the D subgenome. Developing new wheat varieties by integrating the D subgenome from various sources is not only useful for introducing low immunogenic gluten, but it can also circumvent the challenging policies arising from the manipulation of wheat genome through transgenic approaches. Here, we performed RNA amplicon sequencing of the most toxic region of alpha-gliadins to analyze the content and composition of CD-related alpha-gliadin epitopes across eight synthetic wheat lines developed from crosses between durum wheat and different Aegilops species containing the D-genome (Ae. tauschii, Ae. crassa, and Ae. ventricosa). By searching the previously identified 121 epitopes and those with one mismatch in our amplicons, we found 54 different α-gliadins epitopes across our genotypes, four of which were new variants. The canonical epitopes were present in all lines, although their expression patterns varied. The occurrence of DQ2.5-Glia-α1a and DQ2.5-Glia-α3 was higher than that of DQ2.5-Glia-α2 and DQ2.5-Glia-α1b across all genotypes. Since a higher quantity of toxic alpha-gliadin epitopes is associated with increased immunogenicity in individuals susceptible to celiac disease, we measured the frequency of the most toxic alpha-gliadin epitopes among different synthetic lines to estimate the overall immunogenic load of our lines. Generally, the immunogenic load of lines with the D-genome originating from Ae. crassa was much lower than those with the D-genome from Ae. tauschii. In this way, the Ae. tauschii derived lines 5 and 6 contained higher levels of toxic alpha-gliadin epitopes, while lines 3, 4, and 7 (derived from Ae. crassa) contained the lowest levels of toxic peptides. We conclude that replacing the bread wheat D-genome with that of the Ae. crassa may help lower the gluten immunogenicity in the deriving synthetic wheat lines.

Celiac Disease: Beyond Diet and Food Awareness

Celiac disease is attributable to a combination of genetic predisposition and exposure to dietary gluten, with immune system involvement. The incidence is increasing globally, and the societal economic burden of celiac disease stretches beyond the cost of gluten-free food. This enteropathy that affects the small intestine has been related to different disorders and comorbidities. Thus, the implications of suffering from this disease are multidimensional and need further consideration. Celiac disease is a serious condition that remains under-recognized, resulting in an increased need for programs for better management. This review aims to summarize the current evidence regarding celiac diseases, with special emphasis on clinical implications, diagnosis, dietary management, socioeconomical aspects, and future perspectives.

Prevalence and incidence of celiac disease in patients with rheumatoid arthritis: a case-control study based on the RECORD cohort

Background

The reported prevalence of coeliac disease (CD) in rheumatoid arthritis (RA) is variable.

Objective

To evaluate the prevalence and incidence of CD in RA and controls.

Design

Case-control study on administrative data.

Methods

The RECord linkage On Rheumatic Disease database (administrative data, 2004-2013) was used to retrieve patients with RA and age and sex-matched controls. Prevalence and incidence of CD were calculated and stratified according to age, gender, and calendar year.

Results

The cohort included 346,956 subjects (mean age 59.9 (14.5), 70.7% females), of which 70,061 RA and 276,895 controls. Median follow-up was 9 years (IQR 9-9). The prevalence of CD was higher in RA (171/70,061 = 0.24% (0.2-0.3%) vs 398/276895 = 0.14% (0.1-0.2%), p < 0.001). The prevalence of CD among females with RA was increased compared to controls (0.3% vs 0.08%, p < 0.001), but was not increased in males with RA. The incidence was higher in RA and remained stable throughout the observation period.

Conclusion

The prevalence and incidence of CD were increased in RA, particularly in females.

Safety, clinical activity, pharmacodynamics, and pharmacokinetics of IMU-856, a SIRT6 modulator, in coeliac disease: a first-in-human, randomised, double-blind, placebo-controlled, phase 1 trial

BACKGROUND

IMU-856 is an orally available and systemically acting small molecule modulator of sirtuin 6 (SIRT6), a protein that serves as a transcriptional regulator of bowel epithelium regeneration. We aimed to evaluate the safety, clinical activity, pharmacodynamics, and pharmacokinetics of IMU-856 in healthy participants and in patients with coeliac disease.

METHODS

This study reports the results from a completed first-in-human, three-part, double-blind, randomised, placebo-controlled, clinical trial of IMU-856 in healthy participants and patients with coeliac disease done in Australia and New Zealand. In part A, healthy participants were enrolled in six cohorts and randomly assigned (3:1) using a block randomisation algorithm to receive single ascending doses of IMU-856 ranging from 10 mg to 160 mg or matching placebo. Based on the results from part A, three doses were selected for part B to evaluate the safety, tolerability, and pharmacokinetics of IMU-856 once daily for 14 days using the same randomisation algorithm. Part C enrolled patients with well controlled coeliac disease. Participants were centrally randomised 1:1:1 using an interactive web response system to receive either low dose or high dose of IMU-856 or placebo once daily for 28 days that included a 15-day gluten challenge starting on day 14. The primary objective was safety and tolerability of IMU-856. Safety analyses were done on all patients who received at least one dose of the study drug. The trial is registered with the ANZCTR registry (ACTRN12620000901909).

FINDINGS

Between July 27, 2020, and Oct 28, 2022, 71 healthy participants were enrolled in part A and B and assigned to either placebo (n=19) or IMU-856 (n=52). In part A and B, the IMU-856 doses were 10 mg (n=6), 20 mg (n=6), 40 mg (n=13), 80 mg (n=12), 120 mg (n=4), 160 mg (n=11). 43 patients with coeliac disease were enrolled in part C and assigned to either placebo (n=14), IMU-856 80 mg (n=14), or IMU-856 160 mg (n=15). Treatment-emergent adverse events (TEAEs) occurred in 24 (73%) of 33 participants in part A and 15 (79%) of 19 participants in part B receiving any dose of IMU-856 compared with six (50%) of 12 participants in part A and five (71%) of seven participants in part B with placebo. TEAEs were mainly mild in severity. In part C, TEAEs occured in 26 (90%) of 29 patients on any dose of IMU-856 and ten (71%) of 14 receiving placebo; the most common TEAEs with any dose of IMU-856 by preferred term were headache (13 [45%] of 29), nausea (nine [31%]), diarrhoea (eight [28%]), and abdominal distension (seven [24%]). Two serious adverse events occurred with IMU-856 treatment (one in part B [bacterial myocarditis] and one in part C [biliary colic]), both of which were unrelated to IMU-856. No dose-limiting toxicities, systematic safety laboratory changes, or deaths occurred during the study. In part C, mean decrease in villous height was -20·9 μm (SD 34·8) among patients who received IMU-856 80 mg, -22·5 μm (51·1) among those who received IMU-856 160 mg, and -60·3 μm (52·2) among those who received placebo.

INTERPRETATION

The favourable safety profile, along with preliminary activity, suggests that IMU-856 should be studied in future trials of coeliac disease.

FUNDING

Immunic Australia.

Celiac disease care differs significantly between high- and low-middle-income countries: a global survey of celiac experts from 63 countries

BACKGROUND AND AIM

Celiac disease (CeD) is increasingly diagnosed but significant disparities exist in awareness, practices, resources, and legislation worldwide. We conducted a global online survey with CeD experts to assess this disparity internationally.

METHODS

A 55 questions survey encompassing nine domains relevant to CeD care (awareness, gluten-free [GF] foods availability/cost/quality, GF labeling, CeD dietician availability, insurance for CeD patients, medical training, research funding, patient support groups, and unmet needs) was generated and sent to CeD experts worldwide electronically. Countries were stratified based on per capita income as high-income (HIC) and lower-income countries (LIC) (including upper-middle-, lower-middle-, and low-income countries). Survey responses were summarized as a single score using principal component analysis.

RESULTS

Valid responses were obtained from 131(37.4%) [HIC: 71; LIC: 60] of contacted CeD experts from 63 countries. Compared with HIC, LIC experts perceived worse availability (HIC:80% vs LIC: 47%; P < 0.001), quality (52% vs 20%; P < 0.001), and legislation for labeling of GF foods (82% vs 37%; P < 0.001), with unfavorable reimbursement policies (27% vs 12%; P = 0.002), subsidies (32% vs 13%; P < 0.001), and insurance (76% vs 43%; P < 0.001) for CeD patients. LIC also lacked awareness about CeD among general physicians (69% vs 32%; P < 0.001), trained celiac dieticians (39% vs 12%; P = 0.002), and active CeD patient support groups (93% vs 50%; P < 0.001). All experts believed that GF foods were costly (94% vs 87%), frequently contaminated (27% vs 32%), and unfavorably taxed (97% and 93%). The experts agreed on key unmet needs and better research funding. Overall CeD preparedness score (median 58.3 vs 33.0; P < 0.001) was also associated with income.

CONCLUSIONS

The present survey highlights the opinion of global experts on the challenges, opportunities, and preparedness related to CeD and differences worldwide by income.

Gluten-Free Diet Adherence Evaluation in Adults with Long-Standing Celiac Disease

BACKGROUND

Celiac disease (CD) is an autoimmune disease that results from the interaction of genetic, immune, and environmental factors. According to the 2020 European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines, an elimination diet (i.e., excluding products that may contain gluten) is the basic method of treating celiac disease. Following a gluten-free diet is extremely problematic, and patients often make unconscious deviations from the diet. According to the current Oslo definitions for celiac disease, depending on the clinical picture and adequate tests, several forms of celiac disease have been identified: typical, atypical, asymptomatic, potential, and refractory.

OBJECTIVE

The aim of the study was to assess the frequency of conscious diet mistakes and unconscious deviations from a gluten-free diet in a group of patients with long-standing celiac disease and their impact on the frequency of typical and atypical symptoms.

METHODS

The study included 57 people diagnosed with celiac disease between 1980 and 2010. After verifying the history of the disease according to the ESPGHAN guidelines from 2020, we excluded 19 patients who had Marsh grade 1 at the time of diagnosis or those without HLA DQ2 or DQ8 haplotypes detected. After verification, the study included 38 patients, 30 women and 8 men, with a verified diagnosis of typical celiac disease. The effectiveness of the gluten-free diet was assessed in all participants. Blood was collected to determine IgA anti-tissue transglutaminase II antibodies (anti-tTG) and IgG antibodies against deamidated gliadin peptides by ELISA. All survey participants provided data concerning current gastrointestinal and systemic symptoms, bowel habits, comorbidities, dietary habits, physical activity, and socioeconomic conditions.

RESULTS

A total of 25 patients (65.78%) declared strict adherence to the gluten-free diet. However, in this group, seven (18.4%) patients had significantly increased levels of anti-tTG antibodies (mean 82.3 RU/mL ± 78.9 SD at N < 20 RU/mL). Among the patients who consciously made dietary mistakes, six (46.2%) demonstrated increased levels of anti-tTG antibodies. The analysis did not reveal any difference between the frequency of intestinal and extraintestinal symptoms in patients making dietary mistakes and following the gluten-free diet.

CONCLUSIONS

More than half of celiac patients unconsciously or consciously make dietary mistakes, which indicates an urgent need to increase their general knowledge of CD and the appropriate diet. Regardless of whether the gluten-free diet is followed, both typical and atypical symptoms of the disease have been observed among celiac patients.

Celiac Disease, Gluten-Free Diet, and Eating Disorders: From Bench to Bedside

Celiac disease (CD) and eating disorders (EDs) are complex chronic conditions in adolescents, sharing symptoms such as weight change, malnutrition, and gastrointestinal symptoms. CD, an autoimmune disorder triggered by gluten ingestion, is managed through a strict gluten-free diet that can unintentionally foster disordered eating behaviors due to dietary restrictions. Conversely, EDs may mask and complicate CD symptoms, leading to diagnostic delays and treatment challenges. Evidence reveals an increased risk of EDs in CD individuals and vice versa, indicating a potential bidirectional relationship. This review explores the mechanisms and clinical implications of this interplay and proposes integrated screening and care strategies to improve the quality of life for individuals with both conditions.

Clinical Presentations of Celiac Disease: Experience of a Single Italian Center

BACKGROUND/OBJECTIVES

In Italy, the prevalence of celiac disease (CeD) among children exceeds 1.5% and has steadily increased with a linear trend over the past 25 years. The clinical presentation is heterogenous and a change in onset symptoms has been described in recent years. The aim of the study is to describe the pattern of clinical presentation of CeD during the last 12 years in a single Italian center.

METHODS

We retrospectively enrolled all children diagnosed with CeD at Bambino Gesù Children Hospital, Rome between 1 March 2011 and 22 June 2023. To investigate the changes in pattern of clinical presentation, we divided the patient population into three groups of approximately 4 years each (respectively: 49, 48 and 48 months). Patients who previously received a CeD diagnosis in other centers were excluded.

RESULTS

Overall, 4478 patients were diagnosed with CeD at our center. 1082 were excluded, leaving 3396 available for analysis. We divided the study cohort into three groups: group 1 (n = 909), group 2 (n = 1103), and group 3 (n = 1384). Diagnoses of CeD increased by 17.5%. The trend of the non-classic form shows a significative increase (p = 0.000064), showing a high prevalence of bloating and abdominal pain and a significant reduction in celiac crisis (p < 0.0001).

CONCLUSIONS

Annual diagnoses of CeD increased during the study period, and the clinical presentation has changed in recent years, showing an increase in the non-classic form and a reduction in more severe forms of celiac crisis.

Plasma Citrulline in the Diagnosis and Follow-Up of Celiac Disease

BACKGROUND/OBJECTIVES

Citrulline, an amino acid produced by small bowel enterocytes, has been proposed as a potential marker of intestinal absorptive capacity. The aim of this study is to evaluate whether measuring citrulline levels could be useful for celiac disease (CD) patients, both at the time of diagnosis and during follow-up.

METHODS

A multicenter prospective study was conducted. Citrulline levels were measured and compared in 93 pediatric patients classified into three groups. Group A: 28 patients with newly diagnosed CD. In this group, an additional measurement was performed after 3-6 months on a gluten-free diet (GFD). Group B: 32 patients with a prior CD diagnosis and on a GFD for at least 6 months. Group C: 33 healthy controls. Citrulline levels were correlated with clinical and laboratory variables, including serological markers.

STATISTICAL ANALYSIS

t-tests for paired groups and independent groups, Pearson and Spearman correlation tests.

RESULTS

Newly diagnosed CD patients had lower citrulline levels compared to those on a GFD for more than 6 months (27.13 vs. 32.42 µmol/L; p > 0.05). Citrulline levels were nearly identical between healthy controls and CD patients on a GFD for more than 6 months (32.48 vs. 32.42 µmol/L; p > 0.05). Starting a GFD led to a significant increase in citrulline levels in group A (from 27.13 to 37.43 µmol/L, p < 0.001).

CONCLUSIONS

Plasma citrulline could serve as a valuable marker for mucosal recovery in the follow-up of diagnosed celiac patients adhering to a GFD.

Celiac Disease and Liver Damage: The Gut-Liver Axis Strikes Back (Again)? A Retrospective Analysis in the Light of a Literature Review

Background/Objectives: An increasing number of studies have reported liver involvement in both children and adults with celiac disease (CD). This often manifests as isolated hypertransaminasemia or hepatic steatosis (HS). The aim of this study was to define the prevalence of hypertransaminasemia and HS in a pediatric population with CD before starting a gluten-free diet (GFD) and to analyze how the introduction of a GFD could modify this condition. We also conducted a state-of-the-art literature review of the association between hypertransaminasemia, metabolic dysfunction-associated steatotic liver disease (MASLD) and CD. Methods: We retrospectively reviewed the clinical charts of pediatric CD patients diagnosed in three different pediatric units of Sicily, analyzing clinical, laboratory, ultrasound, and histology data before and 12 months after the introduction of a GFD. Results: A total of 160 patients (65.0% females, median age 6.4 (0.8-13.2) years) were included; hypertransaminasemia and HS prevalences at diagnosis were 8.1% and 6.1%, respectively. Subjects with hypertransaminasemia were younger (p = 0.01) than those without and had higher frequencies of HS (p = 0.034) and anti-tissue transglutaminase (tTg) immunoglobulin (Ig)G positivity (p = 0.046). Subjects with HS were younger (p = 0.0001) and had a higher frequency of hypertransaminasemia (p = 0.029) compared to non-steatotic ones. After 12 months of a GFD, hypertransaminasemia and HS persisted in 53.8% and 50.0% of patients, respectively. Conclusions: The prevalences of hypertransaminasemia and HS in Sicilian pediatric CD patients seem to be lower than those reported in other geographical areas. A GFD can reverse the trend of liver involvement, although periods of longer than 12 months may be necessary. However, a GFD has been associated with an increased prevalence of HS, and so regular follow-up involving a nutritionist should be recommended to guide physicians in patient management.

Physical and psychological symptoms and survey importance in celiac disease

Celiac disease is an autoimmune condition that affects approximately 1% of the worldwide community. Originally thought to be confined mostly to the small intestine, resulting in villous atrophy and nutrient malabsorption, it has more recently been implicated in systemic manifestations as well, particularly when undiagnosed or left untreated. Herein, the physical and psychological symptoms of celiac disease are described and explored. An emphasis is placed on efforts to query prospective and confirmed celiac disease patients via the use of surveys. Suggestions are made regarding the development of efficacious surveys for the purpose of screening for celiac disease in undiagnosed persons, and monitoring efficacy of the gluten-free diet in persons diagnosed with celiac disease. There are broad categories of physical and psychological symptoms associated with celiac disease. There is also an essential interaction between such physical and the psychological symptoms. It is important to capture the association between symptoms, via queries directed toward suspected and confirmed persons with celiac disease. The use of anonymous online surveys can be helpful to determine the qualities and characteristics which may be associated with this condition. It is suggested that personal surveys should be given a greater role in screening and to lessen the time for diagnosis. Querying the subject directly via a survey can provide clues as to the types of symptoms being experienced by those with celiac disease currently, as well as to determine the salient aspects of the symptomatology, which will be useful for rapid screening and monitoring in future work.

CRISPR/Cas9-mediated multiplex gene editing of gamma and omega gliadins: paving the way for gliadin-free wheat

Wheat is a staple cereal in the human diet. Despite its significance, an increasing percentage of the population suffers adverse reactions to wheat, which are triggered by wheat gluten, particularly the gliadin fractions. In this study, we employed CRISPR/Cas [clustered regularly interspaced palindromic repeats (CRISPR)/CRISPR-associated protein] multiplexing to introduce targeted mutations into γ- and ω-gliadin genes of wheat, to produce lines deficient in one or both immunogenic gliadin fractions simultaneously. For this study, eight single guide RNAs (sgRNAs) were designed and combined into four plasmids to produce 59 modified wheat lines, of which 20 exhibited mutations in the target genes. Characterization of these lines through Sanger sequencing or next-generation sequencing revealed a complex pattern of InDels, including deletions spanning multiple sgRNAs. The mutations were transmitted to the offspring, and the analysis of homozygous derived lines by reverse-phase HPLC and monoclonal antibodies showed a 97.7% reduction in gluten content. Crossing these lines with other CRISPR/Cas lines deficient in the α-gliadins allowed multiple mutations to be combined. This work represents an important step forward in the use of CRISPR/Cas to develop gluten-free wheat.

The influence of celiac disease on fertility and pregnancy: an Italian survey

BACKGROUND

Celiac disease (CD) is an inflammatory enteropathy that has been associated to obstetric and gynecological disorders. However, it is still not adequately tested by gynecologists due to the misconception that it is solely a gastrointestinal disease. This underestimation requires the development of targeted interventions.

PURPOSE

This study aims to evaluate the association between CD and obstetric/gynecological complications, highlight the importance of informing patients about CD manifestations, and assess the patient satisfaction with the information provided by healthcare professionals on the disease.

METHODS

A digital survey was administered to celiac women via the Italian Celiac Association's website.

RESULTS

We analyzed 493 questionnaires. Obstetric and gynecological disorders led to the diagnosis of CD in 11.7% of interviewed. The study revealed that untreated CD patients are more predisposed to miscarriages (41.8% vs 34% before/after diagnosis, respectively, p = 0.111), anemia in pregnancy (71.4% vs 40.4% before/after diagnosis, respectively, p < 0.001) and the risk of low birth weight (newborns weighing < 1500 g were 4.0% before and 1.1% after the gluten-free diet, p = 0.028). Women with CD, both before and after gluten-free diet, had higher infertility rates (about 19%) than the general population. Additionally, 73% of interviewees were dissatisfied with the information they received from health professionals about the reproductive implications of CD.

CONCLUSION

Our research contributes to a deeper understanding of the intersection between CD and reproductive outcomes, highlighting the main obstetric and gynecological problems related to it. It emphasizes the importance of patient's perspective and the need for greater awareness about celiac disease from healthcare workers.

Extraintestinal complications of celiac disease: treatment considerations

INTRODUCTION

Celiac disease (CD) is an autoimmune enteropathy characterized by atrophy of the intestinal mucosa triggered by the ingestion of gluten in individuals with a genetic predisposition. CD manifests with heterogeneous array of symptoms, including a wide range of intestinal and extraintestinal symptoms and manifestations (EIMs). The mechanisms involved in the pathogenesis of EIMs in CD are not only related to intestinal mucosal damage and associated malabsorption but also to systemic inflammation. To date, the only effective treatment for CD is a lifelong gluten-free diet (GFD). Proper adherence to the GFD leads in most cases to a gradual resolution of intestinal atrophy and results in an improvement of the clinical manifestations associated with intestinal damage.

AREAS COVERED

This review, based on a Pubmed literature search, describes the extraintestinal complications associated with CD, emphasizing strategies for therapeutic management and responsiveness to the GFD.

EXPERT OPINION

CD is associated with different EIMs which can affect different organs. The main clinical interest is if these complications respond to the GFD, which occur at variable rate and not for all disorders associated with CD. Therefore, often complementary additional therapies are needed to achieve optimal symptoms resolution.

Exploring the association between atrial fibrillation and celiac disease: a comprehensive review

Objective

This paper aims to provide a comprehensive overview of the pathophysiology of atrial fibrillation (AF) and celiac disease (CD) individually while also exploring the emerging evidence of a potential association between the two conditions.

Methods

The pathophysiology of AF, the most prevalent arrhythmia globally, and CD, an autoimmune condition triggered by gluten consumption, is examined. Genetic, structural, electrophysiological, and inflammatory factors contributing to their development are explored.

Results

AF involves irregular atrial activity leading to electrical and structural remodeling of the atrium. CD is characterized by an immune response to gluten, primarily associated with HLA-DQ2 and HLA-DQ8 genetic mutations, resulting in damage to intestinal tissue. Emerging research suggests a link between AF and CD, possibly mediated through inflammation, fibrosis, and electromechanical delays in the atrium.

Conclusion

Understanding the association between AF and CD carries significant clinical implications. Recognition of this relationship can assist in identifying individuals at higher risk for AF and inform proactive management strategies. Additionally, it underscores the importance of comprehensive care for CD patients, considering potential cardiac implications. Further research is warranted to elucidate precise mechanisms and explore potential therapeutic interventions targeting common pathways, opening avenues for enhanced patient care and future investigations.

Causal relationships between autoimmune diseases and celiac disease: A Mendelian randomization analysis

The aim of this study was to investigate the causal relationship between autoimmune disorders and celiac disease (CeD) through Mendelian randomization (MR). Single nucleotide polymorphisms (SNPs) significantly associated with 13 autoimmune diseases were extracted from the summary statistics of European genome-wide association studies (GWAS), and their effects were examined by Inverse variance-weighted (IVW) in a large European GWAS on CeD. Finally, reverse MR was performed to investigate the causal effects of CeD on autoimmune traits. Following the application of Bonferroni correction for multiple testing, genetically determined seven autoimmune diseases are causally associated with CeD: Crohn's disease (CD) (OR [95%CI] = 1.156 [1.106 ± 1.208], P = 1.27E-10), primary biliary cholangitis (PBC) (1.229 [1.143 ± 1.321], P = 2.53E-08), primary sclerosing cholangitis (PSC) (1.688 [1.466 ± 1.944], P = 3.56E-13), rheumatoid arthritis (RA) (1.231 [1.154 ± 1.313], P = 2.74E-10), systemic lupus erythematosus (SLE) (1.127 [1.081 ± 1.176], P = 2.59E-08), type 1 diabetes (T1D) (1.41 [1.238 ± 1.606], P = 2.24E-07), and asthma (1.414 [1.137 ± 1.758], P = 1.86E-03). The IVW analysis indicated that CeD increased the risk for seven diseases: CD (1.078 [1.044 ± 1.113], P = 3.71E-06), Graves' disease (GD) (1.251 [1.127 ± 1.387], P = 2.34E-05), PSC (1.304 [1.227 ± 1.386], P = 8.56E-18), psoriasis (PsO) (1.12 [1.062 ± 1.182], P = 3.38E-05), SLE (1.301[1.22 ± 1.388], P = 1.25E-15), T1D (1.3[1.228 ± 1.376], P = 1.57E-19), and asthma (1.045 [1.024 ± 1.067], P = 1.82E-05). The sensitivity analyses deemed the results reliable without pleiotropy. There are positive genetic correlations between various autoimmune diseases and CeD, and the latter also affects the predisposition to multiple autoimmune disorders in the European population.

Development and Validation of a Tool for Assessing Adherence to Gluten-Free Diet in Patients With Celiac Disease

INTRODUCTION

Life-long adherence to gluten-free diet (GFD) and its assessment is essential for patients with celiac disease (CeD). We have developed and validated a tool for assessing adherence to GFD which can be used by both physicians and dietitians.

METHODS

Phase 1: Development, content validation, and assessment of reliability of tool. Phase 2: Validation of tool against standard dietary evaluation (SDE) (gold standard), immunoglobulin A - anti-tissue transglutaminase antibodies (IgA anti-tTG Ab), and gluten immunogenic peptides in urine. Overall, 380 biopsy-confirmed patients with CeD (derivation cohort: n = 100 [phase 1], n = 210 [phase 2] and independent validation cohort, n = 70) were recruited.

RESULTS

Of an initial 90-point questionnaire, 84 items (Celiac Disease: Compliance Assessment Test [CD-CAT.v1]) were retained after content validation and pilot testing. In phase 1, upon administering CD-CAT.v1 on 100 patients, a comprehensive 35-item tool (CD-CAT.v2; α = 0.86) was obtained after removing items with low test-retest reliability and item-rest correlation values. In phase 2, upon administering CD-CAT.v2 on 210 patients, 22 items were removed having low correlation values (R < 0.4) with SDE. Finally, a 13-item tool (CD-CAT.v3; α = 0.84) was obtained with high criterion validity with SDE ( r = 0.806, P < 0.001), moderate convergent validity with celiac disease adherence test ( r = 0.602, P = 0.007), and moderate to weak correlation with urine gluten immunogenic peptides ( r = 0.46, P = 0.001) and IgA anti-tTG Ab ( r = 0.39, P = 0.008), respectively. The final 13-item tool also strongly correlated with SDE ( r = 0.78, P < 0.001) in an independent validation cohort of 70 patients with CeD. Principal component analysis identified 3 relevant subscales with a cumulative variance of 62%. The sensitivity and specificity of CD-CAT.v3 were 80% and 91%, respectively, with an area under curve of 0.905 with SDE. The obtained cutoff score of <19 from the receiver operating characteristic curve was further categorized as 13 = excellent, 14-18 = very good, 19-28 = average, and >28 = poor adherence to GFD.

DISCUSSION

CD-CAT is a new and rapid tool for monitoring dietary adherence to GFD with high sensitivity and specificity, which can be administered by both physicians and dietitians.

Evaluating osteopontin levels in pediatric celiac disease: a potential indicator for mucosal atrophy and osteoporosis

We aim to evaluate the Osteopontin (OPN) levels in patients with Celiac disease (CD) at diagnosis and exploring its association with mucosal atrophy and osteoporosis. The study included celiac patients at diagnosis and age and sex matched healthy controls. Subjects with additional intestinal pathology, other known inflammatory and autoimmune disease accompanying CD, and patients with signs of infection were excluded. Demographics, presenting symptoms, concurrent disorders, physical examination findings, laboratory results, celiac serology and histopathological assessment were recorded. A total of 36 celiac patients (23 girls, 13 boys, mean age 9.4 ± 4.5 years) and 36 healthy controls (22 girls, 14 boys, mean age 8.7 ± 4 years) were included. The median OPN level was significantly higher in patients [10.41 (9.34-13.47) ng/ml vs. 9.42 (7.56-10.19) ng/ml, p < 0.001]. The median OPN levels of patients with osteoporosis was significantly higher than those with normal BMD values [20.7 (10.12-21.22) vs. 9.87 (9.16-10.75), respectively, p = 0.006)]. A serum OPN level of 10.74 ng/ml was found to be a cut-off value for the patient with osteoporosis with 66.7% sensitivity, 66.7% specificity, 50% positive predictive value, and 80% negative predictive value. Patients' OPN levels were 9.53 (9.3-10.42) ng/ml in Marsh type 3a, 9.78 (8.62-15.28) ng/ml in Marsh type 3b and 11.51 (9.88-19.75) ng/ml in Marsh type 3c. Marsh-Oberhuber type 3c was found to have higher median OPN levels than type 3a and type 3b (p = 0.027). When patients were stratified based on their manifestations of either intestinal or extraintestinal symptoms, along with the presence of anemia, tissue TG IgA levels exceeding ten times the upper normal limit, and a deficiency in vitamin D, the median OPN levels exhibited no significant differences across these groups.

CONCLUSIONS

 In conclusion, it is suggested that serum OPN could potentially serve as an indicator of the extent of mucosal atrophy at the initial diagnosis and may have predictive value for osteoporosis.

WHAT IS KNOWN

• There is currently no routinely utilized marker that can ascertain the extent of histological involvement in celiac disease. • Bone mineral density evaluation is not routinely recommendable at diagnosis in celiac disease, as no clinical predictor is available for low bone mineral density in children.

WHAT IS NEW

• Celiac patients have a higher level of osteopontin at diagnosis. • Osteopontin could potentially serve as an indicator of the extent of mucosal atrophy at the initial diagnosis and may have predictive value for osteoporosis.

Clinical outcomes of potential coeliac disease: a systematic review and meta-analysis

OBJECTIVE

Potential coeliac disease (PCD) is characterised by positive serological and genetic markers of coeliac disease with architecturally preserved duodenal mucosa. The clinical outcomes and rates of progression to overt coeliac disease in patients with PCD remain uncertain. In this systematic review and meta-analysis, we aimed to evaluate the clinical outcomes of patients with PCD.

DESIGN

We searched Medline, Embase, Scopus and Cochrane Library from 1991 through May 2024 to identify studies evaluating the clinical outcomes of patients with PCD. The progression rates to villous atrophy, seroconversion and response to a gluten-free diet (GFD) were analysed. A random-effect meta-analysis was performed, and the results were reported as pooled proportions with 95% CIs.

RESULTS

Seventeen studies comprising 1010 patients with PCD were included in the final analyses. The pooled prevalence of PCD among patients with suspected coeliac disease was 16% (95% CI 10% to 22%). The duration of follow-up in most of the studies was at least 1 year, with follow-up periods within individual studies ranging from 5 months to 13 years. During follow-up, 33% (95% CI 18% to 48%; I2=96.4%) of patients with PCD on a gluten-containing diet developed villous atrophy, and 33% (95% CI 17% to 48%; I2=93.0%) had normalisation of serology. Among those who adhered to a GFD, 88% (95% CI 79% to 97%; I2=93.2%) reported symptomatic improvement.

CONCLUSION

Almost a third of patients with PCD develop villous atrophy over time, whereas a similar proportion experience normalisation of serology despite a gluten-containing diet. Most symptomatic patients benefit from a GFD. These findings highlight the importance of structured follow-up and individualised management for patients with PCD.

Beyond diagnosis: exploring coeliac disease incidence alongside clinical and laboratory characteristics of newly diagnosed children in Slovenia

OBJECTIVE

Coeliac disease is characterized by a wide array of clinical presentations. The focus of our study was to comprehensively assess the clinical manifestations of coeliac disease in newly diagnosed children in Slovenia. Our objectives include estimating the incidence of the disease in children in 2022.

METHODS

In this prospective study, Slovenian paediatric gastroenterologists were invited to provide patient data using medical records of children under 19 diagnosed with coeliac disease from March 2021 to October 2023. Patient data were collected through a dedicated web-based form adapted from the CD SKILLS project, including data on clinical manifestations and laboratory results. Furthermore, the study included an estimation of the incidence of coeliac disease in children and adolescents in Slovenia in 2022.

RESULTS

Analysis involved data from 160 children and adolescents (median age: 8 years; 61.9% female). Overall, 16.9% were asymptomatic at diagnosis and 29.4% belonged to a high-risk group for coeliac disease. Among symptomatic cases ( N  = 133), abdominal pain was the leading symptom (44.4%), followed by anaemia (12.0%) and diarrhoea (10.5%). Malabsorption symptoms were more prevalent in very young children. Anaemia was found in 22.8 and 10.7% had abnormal alanine aminotransferase levels. The estimated incidence of coeliac disease in Slovene children in 2022 was 17.5/100 000.

CONCLUSION

Abdominal pain emerged as the primary symptom of coeliac disease in children and adolescents, except in very young children where malabsorption symptoms were predominant. Our observation of a lower prevalence of abnormal liver function tests suggests subclinical coeliac disease may be less common in children. Moreover, the calculated coeliac disease incidence in Slovenia aligns with existing data.

Probiotics: Therapeutic Strategy on the Prevention and Treatment of Inflammatory Diseases: Obesity, Type 2 Diabetes Mellitus and Celiac Disease

Background:

Recent evidence demonstrates the fundamental role of the gut microbiota in inflammatory diseases, and several mechanisms of action of probiotics in improvement of inflammatory parameters.

Objective:

The objective of this review was to relate the consumption of probiotic bacteria and its effects on inflammatory diseases, including obesity, type II diabetes and celiac disease.

Methods:

A search was carried out in English, between the years 2011 and 2022, for research articles and clinical trials with humans and in vivo studies. Research showed improvement in cardiovascular risk markers, and improvement in insulin sensitivity, lipid profile and plasma atherogenic index, in obesity with the use of probiotics. In type II diabetes, decreased levels of fasting glucose, glycated hemoglobin, insulin and glycemic index, and increased levels of peptide 1, superoxide dismutase and glutathione peroxidase were observed.

Results:

In addition to cellular protection of the islets of Langerhans and positive alteration of TNF- α and IL-1β markers. Improvement in the condition of patients with celiac disease was observed, since the neutralization of the imbalance in serotonin levels was observed, reducing the expression of genes of interest and also, a decrease in cytokines.

Conclusion:

Therefore, the use of probiotics should be encouraged.

The Effects of Gluten-free Diet on Body Mass Indexes in Adults with Celiac Disease: A Systematic Review and Meta-analysis of Observational Studies

GOALS AND BACKGROUND

Gluten-free diet (GFD) includes a higher intake of sugars and fats. Previous studies have investigated its effect on body mass index (BMI) in celiac disease (CD) patients but had contradictive conclusions. Thus, we conducted a systematic review and meta-analysis examining the effect of GFD on BMI in CD patients.

STUDY

Systematically, we conducted literature research using Medline, Scopus, and Embase, and we identified 1565 potential studies/abstracts. Only studies of patients with CD under a GFD with recorded BMI before and after dietary intervention were included. Subgroup analyses based on study design and BMI categories were performed. We calculated the pooled odds ratios (ORs) and 95% confidence intervals (Cls) for the number of patients in each BMI group according to the World Health Organization (WHO) definitions after GFD using fixed and random effect meta-analysis.

RESULTS

The analysis included 10 studies and 38 sub-studies/data sets, which encompassed 2450 patients from 5 countries. We found nonsignificant odds for changing the BMI group (pooled OR 0.972, 95% CI: 0.858-1.101, P =0.65) after GFD. However, looking specifically at BMI subgroups, we found higher odds for BMI category change after GFD in underweight patients (OR 0.588, 95% CI: 0.479-0.723, P <0.001), and overweight patients,25

CONCLUSION

Although crucial in patients with CD, GFD is associated with increased BMI in some CD patient populations. Accordingly, special considerations and follow-up should be maintained in overweight patients with CD after GFD.

Collapse

Key Words Collapse

MESH Headings

• Adult
• Humans
• Body Mass Index
• Celiac Disease/diet therapy
• Celiac Disease/physiopathology
• Diet, Gluten-Free
• Observational Studies as Topic
• Overweight

Collapse

Grants Collapse

Affiliation(s)

Noam Peleg The Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv
Yaron Niv School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv
Ram Dickman The Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv
Doron Boltin The Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv
Alex Krauthammer School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hasomer
Michal Herman-Edelstein Department of Nephrology, Rabin Medical Center - Hasharon Hospital School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv
Nidal Issa Department of Surgery B, Rabin Medical Center - Hasharon Hospital, Petach Tikva, Israel School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv
Jacob E Ollech The Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv
Tom Konikoff The Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv
Rachel Gingold-Belfer The Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv

Collapse

Characteristics of Hospitalized Patients With and Without Celiac Disease on a Gluten-Free Diet

BACKGROUND

Most people maintaining a gluten-free diet (GFD) do not have celiac disease (CD). Comorbidities and associated conditions in this population are largely unknown.

AIMS

This study identified demographics, dietary patterns, and diagnoses for patients prescribed a GFD during hospitalization and compared patients with CD to those without CD.

METHODS

We performed a retrospective cross-sectional study for hospital admissions with a GFD between Jan 1, 2010 and June 30, 2022, while excluding patients missing demographic data (n = 113). We compared patients with and without a CD diagnosis, including multivariable logistic regression to identify characteristics independently associated with a CD diagnosis.

RESULTS

We analyzed 1527 hospitalized patients of all ages. A minority (n = 467, 30.6%) carried a CD diagnosis. Age, sex, body mass index, and Medicare/Medicaid enrollment and additional diagnoses associated with a GFD (e.g., IBS) were not significantly different. The CD cohort was more predominantly white (66.6% vs 58.4%, p = 0.007) and non-Hispanic (62.5% vs. 52.7%, p = 0.001). While hospitalized, patients with CD had fewer additional dietary restrictions (mean 0.33 vs 0.56, p < 0.001) and more frequent micronutrient supplementation (26.6% vs 21.4%, p = 0.03). CD was independently associated with malnutrition (OR 1.86, 95% CI 1.31-2.65) and inversely associated with a vegetarian diet (OR 0.35, 95% CI 0.15-0.81), reduced lactose diet (OR 0.25, 95% CI 0.13-0.50), and Hispanic ethnicity (OR 0.56, 95% CI 0.35-0.90) while controlling for other covariates.

DISCUSSION

Two-thirds of hospitalized patients receiving a GFD do not have a diagnosis of CD. Among GFD inpatients, CD is associated with fewer dietary restrictions and independently associated with malnutrition.

Intussusception in children with celiac disease

Celiac disease (CD) is a chronic illness. Blood testing for tissue transglutaminase antibodies is the initial screening test for the diagnosis of CD, and upper gastrointestinal endoscopy and duodenal/jejunal biopsy are used to confirm CD. Intussusception (IS) is the process in which a proximal segment of the bowel invaginates through the lumen of a distal segment. The association between pediatric IS and CD has been described but is still not widely recognized. Herein, we report a case of IS as the first manifestation of CD in a child. A 3-year-old girl presented to the emergency department with a 1-week history of marked abdominal distention and lethargy, but there was no history of fever, bleeding per rectum, or jaundice. A second-degree relative had a family history of CD. Clinical examination: The patient was a lethargic child with pale conjunctiva and bilateral lower limb edema. She was a febrile and had a normal hemodynamic status. The adipose tissue was diminished throughout the patient's body; her weight was 8 kg (<5% weight percentile for girls), and her height was 81 cm (<5% height percentile for girls). Laboratory results included the following: Hb of 9 g/dL, serum ferritin of 10 ng/mL (30-400 ng/mL), normal liver function test results except for hypoalbuminemia at 21 g/L (35-52 g/L), and low blood cholesterol of 0.94 g/L (1.54-2.01 g/L). The patient's blood sugar level was 98 mg/dL, and her renal function test results were normal, with negative septic screening. Abdominal radiography revealed several air-fluid levels, suggestive of an obstruction in the small bowel. Abdominal ultrasonography revealed typical features confirming the diagnosis of IS. Abdominal computed tomography demonstrated an enteroenteric IS with no other signs of organic causes, such as lymphoma or other tumors. Based on the high index of suspicion of CD, a workup confirmed the diagnosis. A gluten-free diet [A1] was started during the hospital course, and the patient improved dramatically regarding her symptoms and was discharged home. In conclusion, this case highlights the association between IS and CD. Intussusception is an emergency condition and usually idiopathic. However, in atypical or recurrent typical presentations underlying causes, we should do proper investigations to initiate appropriate management. [A1]Abbreviations are generally avoided for terms that are not repeated in the text. In this case, this abbreviation is not used elsewhere in the Abstract. Hence, I have deleted the abbreviation. Categories: Pediatrics, Gastroenterology.

Assessment of a training course for cookery students regarding celiac disease and gluten-free diet

Celiac disease (CD) has a significant impact on the quality of life for those affected, particularly in social settings. One major challenge for these individuals is dining out, as they must constantly avoid cross-contact with gluten, contend with a limited range of restaurant options, and often encounter unknowledgeable or misinformed staff. This study aims to evaluate the effectiveness of an educational program designed to enhance the understanding of CD and gluten-free diet (GFD) among future catering staff, thereby improving the social experiences of individuals with CD. A 3-h theoretical and practical session was developed for professional cookery students, focusing on predefined competencies and learning outcomes related to GFD. The study involved a sample of 100 students from Vitoria-Gasteiz, Spain. Following the intervention, students demonstrated increased knowledge regarding gluten content in foods and the application of GFD principles, including cross-contact prevention. However, during the practical activity, the gluten-free dish they prepared was not safe for CD patients to consume. Additionally, the students' perception of the difficulty in providing a GFD remained unchanged. Future sessions should emphasise the importance of interpreting food labels and practising cross-contact prevention. The strong interest in training hospitality students to promote social inclusion of CD patients highlights the need for more programmes to enhance their dining options and safety.

Beyond the gluten-free diet: Innovations in celiac disease therapeutics

Celiac disease (CD) is an autoimmune disorder exacerbated by the ingestion of gluten in genetically susceptible individuals, leading to intestinal inflammation and damage. This chronic disease affects approximately 1% of the world's population and is a growing health challenge due to its increasing prevalence. The development of CD is a complex interaction between genetic predispositions and environmental factors, especially gluten, culminating in a dysregulated immune response. The only effective treatment at present is a strict, lifelong gluten-free diet. However, adherence to this diet is challenging and often incomplete, so research into alternative therapies has intensified. Recent advances in understanding the molecular and immunological aspects of CD have spearheaded the development of novel pharmacologic strategies that should provide more effective and manageable treatment options. This review examines the latest innovations in CD therapies. The focus is on drugs in advanced clinical phases and targeting specific signaling pathways critical to the disease pathogenesis. We discuss both quantitative strategies such as enzymatic degradation of gluten, and qualitative approaches including immunomodulation and induction of gluten tolerance. Innovative treatments currently under investigation include transglutaminase inhibitors, which prevent the modification of gluten peptides, and nanoparticle-based therapies to recalibrate the immune response. These new therapies not only promise to improve patient outcomes but are also expected to improve quality of life by reducing the burden of dietary restrictions. The integration of these new therapies could revolutionize the treatment of CD and shift the paradigm from strict dietary restrictions to a more flexible and patient-friendly therapeutic approach. This review provides a comprehensive overview of the future prospects of CD treatment and emphasizes the importance of continued research and multidisciplinary collaboration to integrate these advances into standard clinical practice.

Role of interleukin-18 in mediating the impacts of celiac disease on osteoporosis: a Mendelian randomization study

Background

Extensive observational data suggest a link between celiac disease (CeD) and osteoporosis, but the causality and mediating mechanism remain undetermined. Herein, we performed a Mendelian randomization (MR) study to address these concerns.

Methods

We obtained the summary-level statistics for CeD from a large genome-wide association study (GWAS) comprising 4,533 cases and 10,750 controls of European ancestry. The GWAS data for osteoporosis-related traits and inflammatory cytokines were derived from the UK Biobank, FinnGen, IEU OpenGWAS database, or GWAS catalog. Two-sample MR with the inverse variance-weighted methods were employed to evaluate the genetic association between CeD and osteoporosis-related traits. The potential inflammatory mediators from CeD to osteoporosis were explored using two-step mediation analyses.

Results

The primary MR analyses demonstrated causal associations between genetically predicted CeD and osteoporosis (odds ratio [OR]: 1.110, 95% confidence interval [CI]: 1.043-1.182, p=0.001), total body bone mineral density (β: -0.025, p=0.039), and osteoporotic fracture (OR: 1.124, 95% CI: 1.009-1.253, p=0.034). Extensive sensitivity analyses consolidated these findings. Among the candidate inflammatory cytokines, only interleukin-18 was observed to mediate the effects of CeD on osteoporosis, with an indirect OR of 1.020 (95% CI: 1.000-1.040, p=0.048) and a mediation proportion of 18.9%. The mediation effects of interleukin-18 could be validated in other datasets (OR: 1.015, 95% CI: 1.001-1.029, p=0.041). Bayesian colocalization analysis supported the role of interleukin-18 in osteoporosis.

Conclusion

The present MR study reveals that CeD is associated with an increased risk of developing osteoporosis, which may be partly mediated by upregulation of interleukin-18.

Laboratory Testing for Celiac Disease: Clinical and Methodological Considerations

BACKGROUND

Celiac disease (CeD) has an estimated prevalence of 1%-3%. The classical clinical presentation is malabsorption, but now patients may present with more subtle symptoms such as constipation, osteoporosis, or iron deficiency anemia. Children may also present with poor growth.CeD has a strong genetic component, and high-risk groups include first-degree relatives with CeD, patients with co-existing autoimmune diseases, and patients with chromosomal aberrations.

CONTENT

Diagnostic tests for CeD include duodenal histology, serology, and genetic testing. Duodenal histology has traditionally been the gold standard of diagnosis. However, serological tests, especially IgA tissue transglutaminase antibodies (TTG-IgA), are widely used and diagnostic algorithms are based primarily on TTG-IgA as a starting point. Human leukocyte antigen typing may also be incorporated to determine genetic risk for CeD. Guidelines for children endorse biopsy avoidance provided high levels of TTG-IgA, with diagnostic accuracy being comparable to duodenal biopsy. Confirmation may be achieved by identifying IgA endomysial antibodies in a separate blood sample. Subjects with low positive TTG-IgA levels and subjects with IgA deficiency need a biopsy to establish a diagnosis of CeD. The clinical follow-up of CeD usually includes a repeat TTG-IgA examination. In adults, healing may be delayed or incomplete, and a rare consequence of refractory celiac disease is transformation to enteric T-cell lymphoma.

SUMMARY

Laboratory testing, in particular TTG-IgA, plays a central role in the diagnosis and has an accuracy comparable to histology. Diagnostic algorithms utilizing laboratory testing are critical for the development of novel strategies to improve diagnosis.