Complications of coeliac disease: are all patients at risk?

Navigating the Challenges of Gluten Enteropathy and Infertility: The Role of Celiac-Related Antibodies and Dietary Changes

Celiac disease (CD) is an autoimmune condition that is initiated in genetically susceptible individuals by the exposure of the intestines to gluten, and the early start of symptoms is related to malabsorption. Atypical variants of the illness are often identified in adulthood and are frequently associated with manifestations outside of the intestines, including metabolic osteopathy, anemia, and dermatitis herpetiformis. But also, empirical data suggest a correlation between CD and reproductive abnormalities, including repeated abortions. Infertility and repeated miscarriages frequently manifest in women diagnosed with CD and may serve as the initial clinical indication of a subclinical form. Furthermore, the condition may manifest as amenorrhea, infertility, and the delivery of infants with a low birth weight. Regarding the mechanisms of CD in infertility, along with the anti-tTG action to hinder the invasiveness of trophoblast, these antibodies could damage endometrial angiogenesis, which has been shown in in vitro models with human endometrial cells and in vivo in murine models. Another important aspect is the role of nutrient deficiencies, such as zinc deficiency (connected to impaired hormone production, secondary amenorrhea, and pre-eclampsia) and folic acid, etc. Therefore, our objective was to conduct a comprehensive review of the existing literature pertaining to this specific topic and to elucidate the role of the autoantibodies in its pathogenesis.

The debate in the diagnosis of coeliac disease - time to go 'no-biopsy'?

PURPOSE OF REVIEW

Duodenal biopsies have been central to making a diagnosis of coeliac disease for the last 70 years. Recent paediatric guidelines have reduced the emphasis on duodenal biopsies with the incorporation of a 'no-biopsy' arm to the diagnostic pathway. This review discusses the no-biopsy approach in adults and highlights advances in alternative (non-biopsy) diagnostic modalities in coeliac disease.

RECENT FINDINGS

Evidence suggests that a no-biopsy approach for the diagnosis of adult coeliac disease is accurate. However, a number of factors still favour duodenal biopsy sampling in specific patient groups. Moreover, several factors need to be considered if this pathway is implemented into local gastroenterology services.

SUMMARY

Duodenal biopsies remain an important step in the diagnosis of adult coeliac disease. However, an alternative approach that removes the necessity for biopsies may be an option in selected adults. If further guidelines incorporate this pathway, then efforts should focus on supporting a dialogue between primary and secondary care to facilitate the appropriate implementation of this approach.

Malignant complications of celiac disease: a case series and review of the literature

BACKGROUND

Celiac disease is an immune-mediated enteropathy triggered by gluten in genetically susceptible individuals. Diagnosis is based on evaluating specific autoantibodies and histopathologic findings of duodenal biopsy specimens. The only therapy for celiac disease is a gluten-free diet. Celiac disease can be complicated by malnutrition, other autoimmune diseases, refractoriness to treatment, and gastrointestinal tumors. This article presents seven cases of malignancies in patients with celiac disease. Its objective is to raise awareness of the malignant complications of celiac disease, leading to earlier diagnosis and improved outcomes.

CASE PRESENTATION

Seven cases of malignant complications of celiac disease occurred among 190 patients followed at the Department of Internal Medicine and Gastroenterology, University Hospital Brno from 2014 to 2021. We describe these cases and the presentation, diagnostic process, course, management, and outcomes for each, along with proposed potential risk factors of malignant complications. There was one Caucasian man who was 70 years old and six Caucasian women who were 36, 46, 48, 55, 73, and 82 years old in our cohort. Of the seven cases of malignancies in our cohort, four patients were diagnosed with small bowel adenocarcinoma, one with diffuse large B-cell lymphoma, one with carcinoma of the tongue, and one with colorectal carcinoma.

CONCLUSIONS

Malignancies occurred in 3.7% of patients followed up for celiac disease. Awareness of the malignant complications of celiac disease, risk factors, presentation, and disease course could lead to earlier diagnosis and improved outcomes.

Characteristics of gluten-free potato dough and bread with different potato starch-protein ratios

The poor retention of fermentation gases and air is a critical issue for gluten-free (GF) products. To better understand the effect of potato flour on the characteristics of GF bread, the mechanistic relations between potato starch and potato protein in different ratios at 9:1, 8:2, 7:3, 6:4 and 5:5 for GF dough were investigated for viscoelasticity, thermal properties, moisture, microstructures, and bread quality. The results reveal that potato starch had a relatively important role in both dough and bread. The viscous character of dough was highest at a proportion of 6:4, with a more compact microstructure and better bread color, volume, hardness, chewiness, resilience and springiness. With decreasing starch content, the gelatinization and retrogradation enthalpy decreased, and the relaxation time of immobilized water and free water increased significantly. These results are believed to be helpful for processors to develop and optimize GF breads with potato starch and potato protein.

Coeliac disease is associated with depression in children and young adults with type 1 diabetes: results from a multicentre diabetes registry

AIMS

To analyse the association between coeliac disease (CD) and depression in children, adolescents, and young adults with type 1 diabetes (T1D).

METHODS

We included 79,067 T1D patients aged 6-20 years, with at least six months of diabetes duration, and treatment data between 1995 and 2019 were documented in the diabetes patient follow-up registry. We categorized patients into four groups: T1D only (n = 73,699), T1 + CD (n = 3379), T1D + depression (n = 1877), or T1D + CD + depression (n = 112).

RESULTS

CD and depression were significantly associated (adjusted OR: 1.25 [1.03-1.53]). Females were more frequent in both the depression and the CD group compared with the T1D only group. Insulin pumps were used more frequently in T1D + CD and T1D + depression compared with T1D only (both p < .001). HbA1c was higher in T1D + depression (9.0% [8.9-9.0]), T1D + CD + depression (8.9% [8.6-9.2]), both compared with T1D only (8.2% [8.2-8.2], all p < .001). We found comorbid autism, attention deficit hyperactivity disorder, anxiety, schizophrenia, and eating disorders more frequently in the T1D + CD + depression group compared with T1D only (all p < .001).

CONCLUSIONS

CD and depression are associated in young T1D patients. The double load of T1D and CD may lead to an increased risk for depression. Depression was associated with additional psychological and neurological comorbidities. Aside from imperative CD screening after T1D diagnosis and regular intervals, depression screening might be helpful in routine care, especially in patients with diagnosed CD.

Well-being and dietary adherence in patients with coeliac disease depending on follow-up

OBJECTIVE

It is not clear how follow-up of coeliac disease should be optimally organised. In Malmö, Sweden, patients are followed up by general practitioners (GP), but in Linköping by gastroenterologists (GE). The aim of this study was to investigate if there were any differences in well-being and dietary adherence depending on type of follow-up.

METHODS

All adult patients with newly diagnosed biopsy-verified coeliac disease in the cities between 2010 and 2014 were offered to participate. Data was retrieved comprising demography, laboratory analyses, questionnaires (Gastrointestinal Symptoms Rating Scale, Short Health Scale, Multidimensional Fatigue Inventory, Psychological General Well-being Index and Short Form 36) and follow-up.

RESULTS

In the GP cohort 39/73 patients and in the GE cohort 58/121 agreed to participate (mean age 43 and 44 years, 69 and 60% women, respectively). A follow-up to a dietician was carried out in 31% and 93% of patients, respectively (p < .001). In the GP group 28% had eaten gluten-containing food during the last 4 weeks compared to 9% in the GE group (p = .01). Despite this, no differences could be seen in vitamin or mineral levels. The questionnaires did not indicate any major discrepancies in subjective health.

CONCLUSION

Irrespective of the design of the follow-up physical and mental well-being were comparable. Dietary adherence was not quite as good in the GP group but follow-up in a primary care setting can still be a suitable and equivalent alternative. However, it is crucial that the dietary counselling is structured in a way that ensures dietary adherence.

The Knowledge About Celiac Disease Among Healthcare Professionals and Patients in Central Europe

OBJECTIVES

Celiac disease (CD) remains undiagnosed for a long time in many adult and pediatric patients. We assessed the knowledge about CD among healthcare professionals (HCPs) and CD patients in Central Europe (CE).

METHODS

HCPs and CD patients from 5 CE countries were asked to complete the web-based questionnaire about CD. The questions were divided into subsections on epidemiology, clinical presentation, diagnostics, treatment, and follow-up. Achieved scores of different specialists managing patients with CD were compared and regional differences in patients' knowledge were analyzed.

RESULTS

Questionnaire was completed by 1381 HCPs and 2262 CD patients or their caregivers from Croatia, Hungary, Germany, Italy, and Slovenia. Mean score achieved by HCPs was 50.9%, and by CD patients 56.4%. Pediatric gastroenterologists scored the highest (69.4%; P < 0.001). There were significant differences in knowledge of patients from different CE regions with German participants scoring the highest (58.3%). Members of CD societies scored higher compared with nonmembers (mean score 58% vs 53.2%; P < 0.001) and patients diagnosed less than 5 years ago scored higher compared with those diagnosed more than 10 years ago (mean score 57.3% vs 54.6%; P < 0.001).

CONCLUSIONS

The knowledge about CD among HCPs and CD patients is not satisfactory. Further awareness-raising and learning activities are needed to improve HCPs' knowledge and to minimize the number of unrecognized patients and unnecessary diagnostic delays. Patients should be better informed about their disease to reach higher compliance with the gluten-free diet.

Progress in the serology-based diagnosis and management of adult celiac disease

Introduction: This article provides a comprehensive overview of the development and application of serological tests used routinely in clinical practice for the diagnosis and management of adult celiac disease.Areas covered: We summarize existing scientific literature related to anti-endomyseal, anti-tissue transglutaminase, and anti-deamidated gliadin peptide antibodies and detail the current and potential future applications of these tests in celiac disease.Expert commentary: Current serological tests in celiac disease have some of the best performance characteristics among disease-specific tests. However, in adult celiac disease, current diagnostic algorithms still rely on duodenal biopsies to confirm the diagnosis. A 'biopsy avoidance strategy' has been implemented in pediatric celiac disease. Future high-quality studies will help inform on whether this approach can be implemented into adult gastroenterology services. It is envisaged that the next 5 years will see an increasing reliance on serology in the diagnosis of adult celiac disease.

Diagnostic Delays in Children With Coeliac Disease in the Central European Region

OBJECTIVES

Coeliac disease (CD) is a systemic autoimmune disorder affecting about 1% of the population. Many patients remain undiagnosed or are diagnosed with substantial delay. We assessed diagnostic delays in symptomatic CD children in Central Europe (CE).

METHODS

Paediatric gastroenterologists in 5 CE countries retrospectively reported data of their patients diagnosed in 2016. Age at first CD-related symptom(s), first visit to paediatric gastroenterologist and confirmed diagnosis were used to determine diagnostic delays.

RESULTS

Data from 393 children (65% girls, median age 7 years, range 7 months to 18.5 years) from Croatia, Hungary, Germany, Italy, and Slovenia were analysed. Median duration from first symptom(s) to visit to paediatric gastroenterologist was 5 months (range 0-10 years; preschool 4 months, school-aged 5 months), and further duration until final diagnosis was 1 month (range 0-5 years) with significant regional differences (P < 0.001). Median diagnostic delay was 6 months (range 0-10 years; preschool 5 months, school-aged 7 months). Type of clinical presentation had little, however, significant effect on delays. Reduced body mass in delays longer than 3 years compared with delays shorter than 1 year was found (z score -0.93 vs -0.39, P < 0.05).

CONCLUSIONS

Time from first symptoms to CD diagnosis in children in 5 CE countries is slightly shorter compared with few other small paediatric studies, and significantly shorter than reported for adults. Nevertheless, delays of more than 3 years in 6.6% of children are worrisome. Raising awareness about the variable symptoms and implementation of reliable diagnostic tools will further reduce diagnostic delays.

Coeliac disease in Caucasian and South Asian patients in the North West of England

BACKGROUND

Coeliac disease is an autoimmune enteropathy characterised by mucosal inflammation subsequent to gluten exposure, leading to malabsorption. Treatment is strict dietary control, relying on the patient's ability to maintain lifestyle modifications. The present study aimed to compare clinical presentation and adherence to a gluten-free diet between South Asian and Caucasian patients with coeliac disease in East Lancashire METHODS: In total, 33 South Asian and 113 Caucasian adult patients diagnosed with coeliac disease under the care of the Dietetics Department at East Lancashire Hospitals NHS Trust were selected using a convenience sampling method and then allocated to the South Asian or Caucasian group. A subjective assessment of dietetic notes from follow-up visits within 1 year of the first appointment was undertaken by two investigators who subsequently allocated the patients to one of the three categories: (i) fully-adherent; (ii) partly-adherent; and (iii) non-adherent. Presenting complaint, vitamin D, vitamin B₁₂ , folate and ferritin levels were also compared.

RESULTS

There was a significant difference in adherence to gluten-free diet between the groups, with a larger proportion of Caucasian patients being fully adherent to gluten-free diet compared to South Asian patients (64.6% versus 12.1%, P < 0.001). In addition, a significantly higher proportion of South Asian patients were vitamin D deficient compared with Caucasian patients (70.8% versus 32.8%, P = 0.002).

CONCLUSIONS

The rates of strict adherence to gluten-free diet and vitamin D levels were significantly lower in South Asian patients with coeliac disease compared to the Caucasian coeliac population. Further studies are required to investigate the causes and improve adherence in the South Asian population.

Algorithms to Define Abnormal Growth in Children: External Validation and Head-To-Head Comparison

BACKGROUND

Growth monitoring of apparently healthy children aims at early detection of serious conditions by use of both clinical expertise and algorithms that define abnormal growth. The seven existing algorithms provide contradictory definitions of growth abnormality and have a low level of validation.

OBJECTIVE

An external validation study with head-to-head comparison of the seven algorithms combined with study of the impact of use of the World Health Organization (WHO) vs national growth charts on algorithm performance.

DESIGN

With a case-referent approach, we retrospectively applied all algorithms to growth data for children with Turner syndrome, GH deficiency, or celiac disease (n = 341) as well as apparently healthy children (n = 3406). Sensitivity, specificity, and theoretical reduction in time to diagnosis for each algorithm were calculated for each condition by using the WHO or national growth charts.

RESULTS

Among the two algorithms with high specificity (>98%), the Grote clinical decision rule had higher sensitivity than the Coventry consensus (4.6% to 54% vs 0% to 8.9%, P < 0.05) and offered better theoretical reduction in time to diagnosis (median: 0.0 to 0.9 years vs 0 years, P < 0.05). Sensitivity values were significantly higher with the WHO than national growth charts at the expense of specificity.

CONCLUSION

The Grote clinical decision rule had the best performance for early detection of the three studied diseases, but its limited potential for reducing time to diagnosis suggests the need for better-performing algorithms based on appropriate growth charts.

FRAX Score Can Be Used to Avoid Superfluous DXA Scans in Detecting Osteoporosis in Celiac Disease: Accuracy of the FRAX Score in Celiac Patients

The Fracture Risk Assessment (FRAX) tool has been developed to estimate patients' 10-yr probability of fracture, thus establishing which patients should undergo dual-energy X-ray Absorptiometry (DXA) scan. This study aimed to evaluate if the FRAX tool can replace or optimize the use of DXA scan in celiac disease (CD). We prospectively enrolled all CD patients aged over 40 yr diagnosed at our third-level unit. At time of CD diagnosis, all patients underwent FRAX score calculation for risk of major osteoporotic and hip fractures and DXA scan (used as gold standard) to assess the accuracy of the FRAX score. The FRAX score calculation was based on the following 10 variables: age (>40 yr), sex (M/F), body mass index, history of previous fracture (yes/no), parent fractured hip (yes/no), current smoking (yes/no), use of steroids (yes/no), rheumatoid arthritis (yes/no), secondary osteoporosis (yes/no), and alcohol ≥3 units/d (yes/no). DXA assessment was performed within 1 week from FRAX calculation. The FRAX score was dichotomized as normal or pathologic in accordance with the National Osteoporosis Guideline Group. A total of 160 CD patients were enrolled (M/F = 20/140; mean age 48.7 yr). A pathologic FRAX score was evident in 14 out of 160 patients (8.7%), whereas osteoporosis based on DXA scan was found in 10 patients (6%) (κ = 0.6); 3 patients with osteoporosis (1.9%) showed a 10-yr risk of major fracture >10% according to the National Osteoporosis Guideline Group criteria. With regard to diagnostic accuracy, the FRAX score showed sensitivity of 0%, specificity of 91%, positive predictive value of 0%, and negative predictive value of 94%. The prevalence of osteoporosis in adult CD appears to be quite low and only a small proportion of patients would require a DXA investigation. The FRAX score could be an effective tool to avoid useless DXA scans in CD patients in view of its high negative predictive value.

Endocrinopathies in celiac disease: When the endocrinologist sees what is invisible to the gastroenterologist

Celiac disease (CD) is a systemic, immune mediated and genetically determined small intestinal disorder characterized by intolerance to dietary gluten that generally presents with gastrointestinal symptoms in young children and extra-intestinal manifestations. Furthermore, there is close association between CD and endocrine diseases, including diabetes, autoimmune thyroid diseases, growth and pubertal disorders, etc. probably due to the presence of a common genetic predisposition. The present review aims to highlight and give more insight to the endocrine changes in CD, especially when there are few or no gastrointestinal symptoms and to emphasize on screening opportunities in some endocrine diseases. (www.actabiomedica.it)

Coexistence of celiac disease & type 1 diabetes mellitus in children

BACKGROUND & OBJECTIVES

Type 1 diabetes mellitus (T1DM) and celiac disease (CD) tend to co-exist due to similar underlying genetic predisposition. Failure to recognize CD in patients with T1DM predisposes them to complications. The present study was aimed to assess children with T1DM for the presence of CD.

METHODS

This was a retrospective analysis of the records of children with T1DM attending paediatric endocrinology clinic at a tertiary care hospital in north India from January 2006 to May 2014. All children were screened for CD at the time of diagnosis of T1DM using IgA anti-tissue transglutaminase (anti-tTG) levels in serum. Seropositive children were subjected to upper gastrointestinal endoscopy and duodenal biopsy for histopathological confirmation. The children also underwent thyroid function testing (TFT); those with deranged TFT were evaluated for thyroid-specific antibodies.

RESULTS

Positive serology for CD was present in 43 of 126 children with T1DM whose records were reviewed [34.1%; 95% confidence interval (CI): 25.9-43.1]. Confirmed CD was diagnosed in 17 (13.5%; CI: 8.1-20.7) of the children screened and 17 of 40 (42.5%; CI: 27.1-59.1) seropositive participants. Four out of 17 children with coexisting CD and T1DM also had autoimmune thyroiditis with overt hypothyroidism. The children with confirmed CD were more likely to have short stature [odds ratios (OR)-3.16; 95% CI: 1.09-9.20, P<0.05] and hypothyroidism (OR-6.4; 95% CI: 1.52-26.90, P<0.05).

INTERPRETATION & CONCLUSIONS

Our study showed a higher proportion of CD in children with T1DM as compared to that reported in general population. Regular screening of children with T1DM for CD is needed to improve metabolic control and prevent long-term complications.

Left ventricular mechanics are affected in children with celiac disease: A study based on two-dimensional speckle tracking echocardiography

BACKGROUND

An association between cardiomyopathy and celiac disease has been reported, but not frequently. We examined the effects on cardiac mechanics in children with celiac disease (CD) by two-dimensional speckle tracking echocardiography (2DSTE).

METHODS

Eighty-one children with CD were compared with a control group comprising 51 healthy children by echocardiographic examination. Children with CD who had been on gluten-free diet for more than 6 months were divided into two different groups: group 1 was positive for serum antitissue transglutaminase antibody (n=48), and group 2 was negative for serum antitissue transglutaminase antibody (n=33). Cardiac functions were evaluated in all children using conventional echocardiography, tissue Doppler imaging (TDI), and 2DSTE methods.

RESULTS

For children with CD, the mean age and male:female ratio were 10.1±4.0 years and 26/55 (67% female), respectively, which did not differ from the controls. Patients were diagnosed at a mean age of 7.9±4.1 years, and the mean follow-up time was 2.37±2.98 years. Conventional echocardiography and TDI measurements did not differ between groups. The left ventricular longitudinal and radial strains, and strain rate values were significantly lower in patients with CD, particularly in those with positive antitissue transglutaminase antibody compared with the control group.

CONCLUSIONS

Our results suggest that 2DSTE is superior to conventional and TDI echocardiography for evaluating subclinical carditis in children with CD.

Celiac Disease: Role of the Epithelial Barrier

In celiac disease (CD) a T-cell-mediated response to gluten is mounted in genetically predisposed individuals, resulting in a malabsorptive enteropathy histologically highlighted by villous atrophy and crypt hyperplasia. Recent data point to the epithelial layer as an under-rated hot spot in celiac pathophysiology to date. This overview summarizes current functional and genetic evidence on the role of the epithelial barrier in CD, consisting of the cell membranes and the apical junctional complex comprising sealing as well as ion and water channel-forming tight junction proteins and the adherens junction. Moreover, the underlying mechanisms are discussed, including apoptosis of intestinal epithelial cells, biology of intestinal stem cells, alterations in the apical junctional complex, transcytotic uptake of gluten peptides, and possible implications of a defective epithelial polarity. Current research is directed toward new treatment options for CD that are alternatives or complementary therapeutics to a gluten-free diet. Thus, strategies to target an altered epithelial barrier therapeutically also are discussed.

Cardiac functions assessment in children with celiac disease and its correlation with the degree of mucosal injury: Doppler tissue imaging study

BACKGROUND/AIMS

Celiac disease (CD)-associated cardiologic disorders is a growing concern. However, data regarding cardiac affection in children with CD are few. This study aimed at assessing the subclinical impact of CD on the global myocardial performance in Saudi children with CD using Doppler tissue imaging (DTI).

PATIENTS AND METHODS

Conventional two-dimensional echocardiography was performed among 20 Saudi children with CDas well as 20 age and sex-matched healthy controls. DTI were used to determine right ventricular (RV) and left ventricular (LV) Tei indexes. These findings were correlated with the Modified Marsh Classification of the histologic findings in CD.

RESULTS

LV and RV Tei indexes were significantly higher in children with CD than the control group (mean ± standard deviation: 0.47 ± 0.05 vs. 0.31 ± 0.18; P< 0.0005 and 0.51 ± 0.04 vs. 0.32 ± 0.05; P< 0.0001, respectively). RV Tei index was found to be positively correlated with the Modified Marsh Classification of CD (r = 0.7753, P< 0.0001). LV Tei index tended to be more affected in patients with more severe histologic findings, however, such relation did not reach statistical significance (r = 0.2479, P = 0.292). Fractional shortening did not correlate with the Modified Marsh Classification of histologic findings in CD patients (r= -0.11, P = 0.641).

CONCLUSIONS

Subclinical myocardial dysfunction of both ventricles occurs in children with CD. The DTI method appears to be more sensitive than conventional two-dimensional echocardiography in the early detection of myocardial dysfunction in children with CD.

Elderly Onset Celiac Disease: A Narrative Review

Celiac sprue is a chronic disease, which usually occurs in children and young adults. However, it can develop in any age group, and the prevalence is increasing even in the elderly population. The atypical patterns of clinical presentation in this age group sometimes can cause a delay in diagnosis. Given the lower sensitivity and specificity of serological tests in the aged population, clinical suspect often arises in the presence of complications (autoimmune disorders, fractures, and finally, malignancy) and must be supported by endoscopic and imaging tools. In this review, we highlight the incidence and prevalence of celiac disease in the elderly, the patterns of clinical presentation, diagnosis, and the most frequent complications, with the aim of increasing awareness and reducing the diagnostic delay of celiac disease even in the elderly population.

Growth trajectories and bone mineral density in anti-tissue transglutaminase antibody-positive children: the Generation R Study

BACKGROUND & AIMS

Increased levels of anti-tissue transglutaminase (tTG) have been associated with reduced weight and bone mineral density (BMD) in symptomatic patients with celiac disease. Little is known about the effects of these antibodies in patients with subclinical or other forms of celiac disease. We examined associations between anti-tTG positivity and growth and BMD.

METHODS

In a population-based prospective cohort study, serum samples were collected from children (median age, 6 years; n = 4442) and analyzed for anti-tTG. All children were born between April 2002 and January 2006 and were not previously diagnosed with celiac disease. Children were categorized as anti-tTG negative (<7 U/mL, n = 4249) or anti-tTG positive (≥7 U/mL, n = 57). Children's levels of anti-tTG were further categorized on the basis of ≥10 times upper limit of normal (70 U/mL). Height, weight, and body mass index (BMI) age- and sex-adjusted standard deviation scores (SDS) ([observed value - mean]/SD) were obtained by using Dutch reference growth charts. BMD was measured by dual-energy x-ray absorptiometry. Multivariable linear regression and linear mixed models were performed.

RESULTS

Children who tested positive for anti-tTG had reduced growth in weight SDS/year (reduction of 0.05; 95% CI, reductions of 0.09-0.01) and BMI SDS/year (reduction of 0.10; 95% CI, reductions of 0.18-0.01) from 6 months until 6 years, compared with children without anti-tTG; they also tended to have reduced growth in height from 6 months until 6 years (reduction of 0.02 SDS/year; 95% CI, reductions of 0.06-0.02). Children who tested positive for anti-tTG were shorter (0.29 SDS shorter; 95% CI, reductions of 0.55-0.04 SDS), weighed less (0.38 SDS less; 95% CI, reductions of 0.64-0.12), and had lower BMIs (0.26 SDS less; 95% CI, reductions of 0.49-0.03) and BMDs (0.26 SDS less; 95% CI, reductions of 0.45-0.08) at 6 years of age than anti-tTG negative children.

CONCLUSIONS

Anti-tTG positive children without gastrointestinal symptoms have lower BMDs and reduced growth trajectories until they are 6 years old. This suggests that subclinical or potential celiac disease can affect BMD and growth.

Assessing Nutritional Quality and Adherence to the Gluten-free Diet in Children and Adolescents with Celiac Disease

PURPOSE

Little is known regarding nutritional adequacy of the gluten free diet (GFD) in children and adolescents with celiac disease (CD). The study aim was to examine macro- and micronutrient intake in children with CD.

METHODS

A cross-sectional study was conducted in children and adolescents (4-18 years of age) with CD (n = 32) and healthy controls (n = 32). Macro- and micronutrient intake, and glycemic index (GI) and glycemic load (GL) intake was assessed using validated measures. Diet quality was assessed using the Canadian Healthy Eating Index (HEI-C) and the Alberta Nutrition Guidelines. Values are shown as mean ± SE.

RESULTS

Age (10.4 ± 0.7 years vs 8.7 ± 0.7 years; P = 0.06), weight-for-age z score (P = 0.27), and height-for-age z score (P = 0.23) were not different between groups. CD children consumed more fibre (15.9 ± 1.2 g per day(CD) vs 10.8 ± 0.8 g per day (controls); P < 0.001), had higher GI (CD: 54 ± 2 vs 48 ± 1; P < 0.01) and GL (CD: 118 ± 8 vs 93 ± 7; P = 0.02), and lower folate (146.7 ± 15.3 (CD) vs 245.4 ± 21.8 µg per day (controls); P < 0.001) than controls. No differences in HEI-C scores (≤ and > 80) were observed between groups (P > 0.05).

CONCLUSION

Children with CD had high intakes of fibre, GI, and GL and lower intakes of folate. This has implications for dietary counselling in this population.

Coeliac disease presenting as severe hypoglycaemia in youth with type 1 diabetes

BACKGROUND

Coeliac disease is an autoimmune disorder classically characterized by gastrointestinal symptoms and poor growth. The disease can be difficult to recognize in patients with Type 1 diabetes mellitus. Some clinicians find treatment of the disease in asymptomatic individuals controversial.

CASE REPORTS

Two adolescent female patients with Type 1 diabetes experienced recurrent hypoglycaemic seizures. Neither patient reported gastrointestinal symptoms or poor growth. After diagnosis and treatment of coeliac disease, hypoglycaemia resolved.

CONCLUSION

These cases illustrate how frequent unexplained severe hypoglycaemia can be an atypical presentation of coeliac disease in youth with Type 1 diabetes. Furthermore, they emphasize the importance of screening and treatment of coeliac disease in asymptomatic patients with Type 1 diabetes. Although controversial, management of coeliac disease in these asymptomatic patients can prevent the vicious cycle of recurrent hypoglycaemia and decrease risk for morbidity and death.

Celiac disease and risk of fracture in adults--a review

Patients with celiac disease (CD) have low bone mineral density. Evidence of increased fracture risk in these patients is conflicting, and the indication for bone mineral density screening of all adult CD patients is debated. Our aim was to review current published data on fractures in CD. Cross-sectional cohort studies and one case study were identified by searching Medline and Embase. Although the identified studies are heterogeneous and difficult to compare, the overall findings indicate a positive association between CD and risk of fracture. Adult patients with CD should be considered for bone densitometry in order to estimate fracture risk.

Issues associated with the emergence of coeliac disease in the Asia–Pacific region: a working party report of the World Gastroenterology Organization and the Asian Pacific Association of Gastroenterology

BACKGROUND AND AIM

Once thought to be uncommon in Asia, coeliac disease (CD) is now being increasingly recognized in Asia–Pacific region. In many Asian nations, CD is still considered to be either nonexistent or very rare. In recognition of such heterogeneity of knowledge and awareness, the World Gastroenterology Organization and the Asian Pacific Association of Gastroenterology commissioned a working party to address the key issues in emergence of CD in Asia.

METHODS

A working group consisting of members from Asia–Pacific region, Europe, North America, and South America reviewed relevant existing literature with focus on those issues specific to Asia–Pacific region both in terms of what exists and what needs to be done.

RESULTS

The working group identified the gaps in epidemiology, diagnosis, and management of CD in Asian–Pacific region and recommended the following: to establish prevalence of CD across region, increase in awareness about CD among physicians and patients, and recognition of atypical manifestations of CD. The challenges such as variability in performance of serological tests, lack of population-specific cut-offs values for a positive test, need for expert dietitians for proper counseling and supervision of patients, need for gluten-free infrastructure in food supply and creation of patient advocacy organizations were also emphasized.

CONCLUSIONS

Although absolute number of patients with CD at present is not very large, this number is expected to increase over the next few years or decades. It is thus appropriate that medical community across the Asia–Pacific region define extent of problem and get prepared to handle impending epidemic of CD.

Coeliac disease in a 15-year period of observation (1997 and 2011) in a Hungarian referral centre

AIMS

The aim of this study is to evaluate the experience of a single coeliac centre over a 15-year-long study period (between November of 1997 and September of 2011).

PATIENTS AND METHODS

Charts of 178 patients (139 females) with coeliac disease were retrospectively evaluated. Tests performed: multiple duodenal biopsies, anti-tissue transglutaminase and anti-endomysium antibodies, body mass index calculation, osteodensitometry, evaluation of disorders associated with coeliac disease, and implementation of family screening.

RESULTS

Histological samples were available in 133 cases, distribution according to Marsh-Oberhuber classification: M0 in 7%, M1-M2 in 4%, M3a in 26%, M3b in 13%, and M3c in 50% of cases, respectively. Anti-tissue transglutaminase and anti-endomysium antibody tests were available in 158 cases, 132/158 showed seropositivity. Mean body mass index values were 23.05kg/m(2) for males, and 21.07kg/m(2) for females, respectively. Osteodensitometry showed normal values in 46%, osteopenia in 36%, and osteoporosis in 18% of cases, respectively. Coeliac disease associated disorders was present in 63/178 (35%) patients. Ninety coeliacs brought 197 first degree relatives for screening, with 47/197 (23%) relatives proving to have coeliac disease. Correlations between anti-tissue transglutaminase antibody titres and Marsh-Oberhuber classification, and anti-tissue transglutaminase antibody titres and bone mineral density values were found to be statistically significant (p=0.0011, and p=0.001, respectively).

CONCLUSIONS

Coeliac disease can become overt at any age. Female predominance is significant. Histology usually showed advanced villous atrophy. Mean body mass index values were within normal range. The high prevalence of associated disorders is also noted. The prevalence of 24% of coeliac disease among first degree relatives underlines the necessity of family screening.

Methods to obtain referral criteria in growth monitoring

An important goal of growth monitoring is to identify genetic disorders, diseases or other conditions that manifest themselves through an abnormal growth. The two main conditions that can be detected by height monitoring are Turner’s syndrome and growth hormone deficiency. Conditions or risk factors that can be detected by monitoring weight or body mass index include hypernatremic dehydration, celiac disease, cystic fibrosis and obesity. Monitoring infant head growth can be used to detect macrocephaly, developmental disorder and ill health in childhood. This paper describes statistical methods to obtain evidence-based referral criteria in growth monitoring. The referral criteria that we discuss are based on either anthropometric measurement(s) at a fixed age using (1) a Centile or a Standard Deviation Score, (2) a Standard Deviation corrected for parental height, (3) a Likelihood Ratio Statistic and (4) an ellipse, or on multiple measurements over time using (5) a growth rate and (6) a growth curve model. We review the potential uses of these methods, and outline their strengths and limitations.

Bone mineral density directly correlates with duodenal Marsh stage in newly diagnosed adult celiac patients

OBJECTIVES

To estimate the prevalence of low bone mineral density (BMD) in a prospective series of adult celiac patients and to identify nutritional and metabolic factors associated with osteoporosis and osteopenia.

METHODS

Patients over 18 years of age who were consecutively and newly diagnosed with celiac disease (CD) were recruited. A bone density scan with dual-energy X-ray absorptiometry was carried out on the left hip and lumbar spine; nutritional parameters were analyzed and a hormone study conducted in order to exclude secondary low BMD.

RESULTS

40 patients (36 females/4 males) between the ages of 18 and 68 (mean 44.25 years) were recruited. Overall, at the moment of diagnosis 45% of patients exhibited low BMD at both demarcations. Risk of hip fracture was generally low, but ascended to mild in patients with villous atrophy (p = 0.011). Differences in major fracture risk were also observed depending on Marsh stage (p = 0.015). Significant differences were observed in nutritional status between patients with and without duodenal villous atrophy, with body mass index and blood levels of prealbumin, iron, vitamin D and folic acid significantly lower in Marsh III stage patients. No differences were found in blood hormone levels between Marsh stages or BMDs. The degree of bone mass loss in the lumbar spine directly correlated to Marsh stage. In the hip, a parallel association between BMD and Marsh stage was also observed, but did not reach statistical significance.

CONCLUSION

Duodenal villous atrophy, through malabsorption, was the main determinant factor for low BMD in adult-onset CD patients.

Small bowel endoscopy and coeliac disease

Coeliac disease (CD) is a gluten-responsive, chronic inflammatory enteropathy that shares many features with classical autoimmune diseases. Coeliac disease affects about 1-2% of Caucasians, North Africans and Asians who possess the necessary susceptibility genes encoding HLA DQ2 or HLA DQ8. It is not only unique among the autoimmune diseases in that the precise trigger (gluten from wheat, rye and barley) has been identified, but also in that it has lent itself well to advancements in endoscopic imaging. Since its introduction, flexible endoscopy has allowed tissue to be collected from the small bowel with relative ease and safety, and recently has facilitated direct imaging and sampling of the entire small intestine. It is now fifty years since the Crosby capsule first allowed clinicians the ability to non-surgically biopsy the small bowel leading to an enhanced diagnosis of coeliac disease. The introduction of wireless video capsule endoscopy (VCE), small bowel enteroscopy and in particular double balloon enteroscopy (DBE), have expedited the accurate diagnosis of coeliac disease and its more serious complications such as small bowel adenocarcinoma, refractory coeliac disease type II (RCDII) and enteropathy associated T cell lymphoma (EATL).

Screening for unrecognized coeliac disease in subfertile couples

OBJECTIVE

Subfertility has been reported as a long-term complication of unrecognized and/or untreated coeliac disease (CD); however, the results from studies on this topic are ambiguous. We aimed to determine the prevalence of unrecognized CD in subfertile male-female couples visiting a fertility clinic compared with the general population.

METHODS

Subjects included 1038 male-female couples (n = 2076) who visited the fertility clinic of the Leiden University Medical Center in the Netherlands between 2003 and 2009. All consecutive patients were routinely, serologically screened, and those with positive test results for antibodies against IgA anti-tissue transglutaminase type 2 and IgA endomysial antibodies were considered to have unrecognized CD. Clinical data on gender, age, height, weight, diagnosis of subfertility, and previously diagnosed CD were collected from the clinical files. Subsequently, after serological screening, all patients were anonymized. The prevalence of unrecognized CD was compared with the one in the general adult population in the Netherlands (0.35%).

RESULTS

The prevalence of unrecognized CD in subfertile male-female couples was 0.48% (10/2076; 6 females and 4 males) and was not significantly more frequent compared with the general population. Compared with the control group, similar CD prevalences were found within the different subfertility categories separately: unexplained subfertility, anovulation, tubal pathology, and male factor (p = NS).

CONCLUSION

In our large study cohort of subfertile male-female couples, the prevalence of unrecognized CD is comparable to the general population in the Netherlands. No association was observed between CD and subfertility in the different subfertility categories and genders.

Coeliac Disease in the 21st Century: No Longer "Kids' Stuff"

Background

We aimed to determine if Coeliac disease (CD) can be still be considered a predominantly paediatric disorder, in spite of the increased incidence of adult-onset CD reported in recent years.

Methods

An observational, descriptive, and retrospective study was developed at two Spanish hospitals. Data was collected and analyzed from all paediatric and adult patients newly diagnosed with CD throughout the year 2010. CD diagnoses were based on a concordant clinical history, serology, HLA-DQ compatibility, the presence of mucosal lesions in duodenal biopsies with gluten dependence of symptoms, and histological lesions.

Results

A total of 79 patients were diagnosed with CD throughout 2010, of which 68 (86.1%) were adults. Classic symptoms (diarrhoea and iron-deficiency anaemia) were more frequent in children (90.9%), being present in only 54.4% of adults (p = 0.02). Adult patients showed, mainly, abdominal pain, dyspepsia, and GERD-related symptoms. Villous atrophy (Marsh III) was present in 63.7% of children, but only in 19.1% of adults (p = 0.004). Positive tTGA was present in 81.8% of the children and only in 19.1% of the adults (p = 0.004). Haemoglobin levels were significantly lower in children (p = 0.025), but no differences were observed in iron and ferritin blood levels.

Conclusions

Our study shows that adult-onset CD was the predominant presentation in two hospitals in Spain in the year 2010. Therefore, CD can no longer be considered a predominantly paediatric disorder. Marsh I and negative tTGA titters are characteristic in most of adults. New diagnostic algorithms are needed to improve correct diagnosis of CD in adults.

Celiac disease presenting as severe osteopenia

The authors describe a unique presentation of celiac disease as multiple non-traumatic fractures in a young male without gastrointestinal complaints. A 29-year-old man presented with back pain and was found to have a non-traumatic compression fracture of the lumbar and thoracic spine on plain X-ray. Dual-energy x-ray absorptiometry (DXA) confirmed osteoporosis at the L3/L4 vertebral bodies. Parathyroid hormone (PTH), calcium, and vitamin D levels were normal. He had no gastrointestinal complaints, but serologic studies were positive to include an elevated gliadin IgA Ab, gliadin IgG Ab, and an elevated tissue transglutaminase IgA Ab. He was treated with a gluten-free diet, calcium, and vitamin D supplementation as well as teriparatide. Follow up bone density showed improvement and has no further fractures to date. Primary care physicians, gastroenterologists, and endocrinologists must have a high index of clinical suspicion for celiac disease in any patient who presents with low bone density regardless of the serum 25-OH vitamin D levels or presence of gastrointestinal complaints.

Resolution of metabolic syndrome after following a gluten free diet in an adult woman diagnosed with celiac disease

Adult celiac disease (CD) presents with very diverse symptoms that are clearly different from those typically seen in pediatric patients, including ferropenic anemia, dyspepsia, endocrine alterations and elevated transaminase concentration. We present the case of a 51-year-old overweight woman with altered basal blood glucose, hypercholesterolemia, hypertriglyceridemia and persisting elevated transaminase levels, who showed all the symptoms for a diagnosis of metabolic syndrome. Because she presented iron deficiency anemia, she was referred to the gastroenterology department and subsequently diagnosed with celiac disease after duodenal biopsies and detection of a compatible HLA haplotype. Gluten-free diet (GFD) was prescribed and after 6 mo the patient showed resolution of laboratory abnormalities (including recovering anemia and iron reserves, normalization of altered lipid and liver function parameters and decrease of glucose blood levels). No changes in weight or waist circumference were observed and no significant changes in diet were documented apart from the GFD. The present case study is the first reported description of an association between CD and metabolic syndrome, and invites investigation of the metabolic changes induced by gluten in celiac patients.

Unexplained infertility as primary presentation of celiac disease, a case report and literature review

BACKGROUND

Celiac sprue (gluten sensitive enteropathy) is an autoimmune disease which is hereditary and its pathology mainly bases on immunologic intolerance to gluten. It has a vast variety of signs and symptoms and its clinical features range from a silent disease to a typical gastrointestinal disorder. In this study we reviewed and summarized some other related issues about this disease and its relation with infertility.

CASE

The case is a 26 years old lady who had referred to a gynecologist because of infertility for 2 years and later it revealed that she has celiac sprue.

CONCLUSION

Screening for its silent or subtle types especially among suspicious cases such as unexplained infertility seems to be a cost effective action. Meanwhile, in time administration of a gluten-free diet can lead to an almost complete cure.

Celiac disease and the gluten-free diet

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

Complications in celiac disease under gluten-free diet

We assessed the onset of malignant and nonmalignant complications in a cohort of celiac disease (CD) patients under gluten-free diet (GFD). Five hundred and forty-nine CD patients were retrospectively assessed. Two hundred and fifty-one (45.7%) showed classical, 262 (47.7%) subclinical, and 36 (6.6%) silent form of CD at the time of the diagnosis. The mean time under GFD was 7.13 years (range 1-15 years). Out of 549 patients, 381 (69.4%) were fully compliant, 112/549 (20.4%) reported less than one dietary transgression/month, and 56/549 (10.2%) reported at least one dietary transgression/month. Out of 549 patients, 18 (3.3%) patients developed complications under GFD (seven malignant and 11 nonmalignant complications). Fourteen patients were previously affected by classical CD (5.6% of the overall patients with classical CD), and four were affected by subclinical CD (1.5% of the overall patients with subclinical CD). None of the patients affected by silent CD developed complications. There was no statistical difference between the mean age of the two groups developing complications (P = n.s.). Complications appeared after a mean time under GFD of 6.5 years in classical CD, and after a mean time of 3.5 years in subclinical CD (P = n.s.). Finally, 6/14 (42.8%) patients with classical CD were not fully compliant to GFD, while 2/4 (50%) of subclinical CD patients were not fully compliant to GFD (P = n.s.). Less than 5% of CD patients may develop complications under GFD. Complications seem to affect more classical CD than subclinical CD, and seem to be irrespective of optimal GFD adherence.

Celiac disease in the elderly

It has become apparent recently that celiac disease, once believed to be primarily a childhood disease, can affect people of any age. Epidemiologic studies have suggested that a substantial portion of patients are diagnosed after the age of 50. Indeed, in one study, the median age at the diagnosis was just under the age of 50 with one-third of new patients diagnosed being older than 65 years. The purpose of this review is to address the prevalence, clinical features, diagnosis, and consequences of celiac disease in the elderly. The authors also review management strategies for celiac disease and adjust these with emphasis on the particular nutritional and nonnutritional consequences or associations of celiac disease as they pertain to the elderly.

Recent advances in coeliac disease

PURPOSE OF REVIEW

Worldwide awareness of coeliac disease in all ages continues to grow. This article aims to summarize critically the recent research advances in coeliac disease.

RECENT FINDINGS

Large multicentre studies have provided further evidence of the role of environmental and nonhuman leucocyte antigen genetic factors in coeliac disease. Siblings of coeliac patients carry a high risk, but those found to have negative coeliac serology are very unlikely to develop the disease. Advances in the efficacy of serological antibody testing potentiate the possibility of future accurate screening programmes in the community. Adherence to a gluten-free diet remains paramount as the recognition of coeliac related complications increases.

SUMMARY

Despite the encouraging progress that has taken place in our genetic and immunological knowledge of coeliac disease, early introduction of a gluten-free diet remains the cornerstone of treatment. Alternatives, however, aimed at altering the toxicity of cereal proteins are now looking more promising.

Bone mineral content deficits of the spine and whole body in children at time of diagnosis with celiac disease

BACKGROUND

The aim of this study was to determine whether children with celiac disease (CD) have deficits in spine (SP) and whole body (WB) bone mineral content (BMC) at time of diagnosis, and whether the deficits are related to altered growth and body composition. The secondary aim was to examine the effect of histological grade on BMC.

PATIENTS AND METHODS

A retrospective study of children who had undergone a dual energy x-ray absorptiometry scan at the time of diagnosis with CD between October 1, 2003, and June 15, 2006, were compared with a healthy reference sample of similar age and race from the same geographic region in the United States. SP and WB BMC were expressed as sex-specific z scores relative to age and relative to height to assess differences in the CD group versus controls. Pearson correlation, t tests, and analysis of variance were performed to determine predictors of BMC.

RESULTS

Forty-four children (mean age 10.6 +/- 3.4 years; 77% female, 96% white) with CD were evaluated and compared with 338 healthy children. Children with CD were shorter than children of similar age and sex. SP and WB BMC for age z scores were significantly lower in the CD group compared with controls. When adjusted for height, significant deficits in WB BMC persisted in patients with CD. Low SP and WB BMC correlated with advanced histological grade in CD. Low body mass index correlated with low WB BMC in CD.

CONCLUSIONS

Newly diagnosed children with CD may benefit from screening for low bone mineral content. Patients with low body mass index and those with advanced histological damage (Marsh grade IIIc) particularly may be at risk for osteopenia.

Screening rules for growth to detect celiac disease: a case-control simulation study

Background

It is generally assumed that most patients with celiac disease (CD) have a slowed growth in terms of length (or height) and weight. However, the effectiveness of slowed growth as a tool for identifying children with CD is unknown. Our aim is to study the diagnostic efficiency of several growth criteria used to detect CD children.

Methods

A case-control simulation study was carried out. Longitudinal length and weight measurements from birth to 2.5 years of age were used from three groups of CD patients (n = 134) (one group diagnosed by screening, two groups with clinical manifestations), and a reference group obtained from the Social Medical Survey of Children Attending Child Health Clinics (SMOCC) cohort (n = 2,151) in The Netherlands. The main outcome measures were sensitivity, specificity and positive predictive value (PPV) for each criterion.

Results

Body mass index (BMI) performed best for the groups with clinical manifestations. Thirty percent of the CD children with clinical manifestations and two percent of the reference children had a BMI Standard Deviation Score (SDS) less than -1.5 and a decrease in BMI SDS of at least -2.5 (PPV = 0.85%). The growth criteria did not discriminate between the screened CD group and the reference group.

Conclusion

For the CD children with clinical manifestations, the most sensitive growth parameter is a decrease in BMI SDS. BMI is a better predictor than weight, and much better than length or height. Toddlers with CD detected by screening grow normally at this stage of the disease.

Effect of a gluten-free diet on the risk of enteropathy-associated T-cell lymphoma in celiac disease

Patients with celiac disease have an increased rate of enteropathy-associated T-cell lymphoma, but conflicting data are available about the protective role of a gluten-free diet with regard to the development of this malignancy. We followed 1,757 celiac patients for a total period of 31,801 person-years, collecting data about the frequency of gluten intake and the incidence of the enteropathy-associated T-cell lymphoma. Out of the nine celiac patients who developed an intestinal lymphoma [standard morbidity ratio of 6.42 (95% CI = 2.9-12.2; P < 0.001)], only two kept a strict gluten-free diet after the diagnosis of celiac disease and developed the malignancy after the peridiagnosis period of 3 years, dropping therefore the standard morbidity ratio to 0.22 (95%CI = 0.02-0.88; P < 0.001). The risk of developing an intestinal lymphoma for the celiac patients that used to have dietary gluten was significant (X(2 )= 4.8 P = 0.01). These results show that a strict gluten-free diet is protective towards the development of enteropathy-associated T-cell lymphoma.

Coeliac disease in primary care

Is common, underdiagnosed, and can present with non-specific symptoms