Motility Disorders in Celiac Disease and Non-Celiac Gluten Sensitivity: The Impact of a Gluten-Free Diet

Coeliac disease is a strong risk factor for Gastro-oesophageal reflux disease while a gluten free diet is protective: a systematic review and meta-analysis

Background

Gastro-oesophageal reflux disease (GORD) mechanisms are well described, but the aetiology is uncertain. Coeliac disease (CD), a gluten enteropathy with increased duodenal eosinophils overlaps with GORD. Functional dyspepsia is a condition where duodenal eosinophilia is featured, and a 6-fold increased risk of incident GORD has been observed. Perturbations of the duodenum can alter proximal gastric and oesophageal motor function. We performed a systematic review and meta-analysis assessing the association between CD and GORD.

Methods

A systematic search of studies reporting the association of GORD and CD was conducted. CD was defined by combined serological and histological parameters. GORD was defined based on classical symptoms, oesophagitis (endoscopic or histologic) or abnormal 24-h pH monitoring; studies reporting oesophageal motility abnormalities linked with GORD were also included. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using a random-effects model.

Findings

31 papers were included. Individuals with CD on a gluten containing diet were 3 times more likely to have GORD than controls (OR: 3.37, 95% CI: 2.09-5.44), and over 10 times more likely when compared to those on a gluten free diet (GFD) (OR: 10.20, 95% CI: 6.49-16.04). Endoscopic oesophagitis was significantly associated with CD (OR: 4.96; 95% CI: 2.22-11.06). One year of a GFD in CD and GORD was more efficacious in preventing GORD symptom relapse than treatment with 8 weeks of PPI in non-CD GORD patients (OR: 0.18, 95% CI: 0.08-0.36). Paediatric CD patients were more likely to develop GORD (OR: 3.29, 95% CI: 1.46-7.43), compared to adult CD patients (OR: 2.55, 95% CI: 1.65-3.93).

Interpretation

CD is strongly associated with GORD but there was high heterogeneity. More convincingly, a GFD substantially improves GORD symptoms, suggesting a role for duodenal inflammation and dietary antigens in the aetiology of a subset with GORD. Ruling out CD in patients with GORD may be beneficial.

Funding

The study was supported by an Investigator Grant from the NHMRC to Dr. Talley.

Duodenojejunal inflammation causing chronic vomiting in adult-onset Still's disease

Adult-onset Still's disease (AOSD) is a rare systemic autoinflammatory disease with a broad spectrum of clinical manifestations including fever, skin rash, arthralgia and neutrophilic leucocytosis. Small bowel inflammation in AOSD has been reported in association with Crohn's disease, coeliac disease and chronic intestinal pseudo-obstruction. We have here reported the first-time case of AOSD with small bowel involvement, presenting with chronic vomiting. Fluorodeoxyglucose total-body positron emission tomography/CT showed high uptake of the duodenum and first jejunal loop. Faecal calprotectin increased. Duodenal histology revealed neutrophilic infiltrate among duodenal enterocytes and severe chronic lymphoplasmacellular infiltrate of the lamina propria. Vomiting disappeared when duodenojejunal inflammation was controlled by immunomodulatory treatments for AOSD, suggesting a possible causal relation between duodenojejunal inflammation and the symptom.

Celiac Disease and Gallbladder: Pathophysiological Aspects and Clinical Issues

Background: Celiac Disease (CD) is an immune-mediated disorder which primarily affects the small intestine; however, extra-intestinal organs are often affected by the pathological process, too. As regards the digestive system, liver alterations in CD patients have been widely described, which can also extend to the biliary tract. Notably, gallbladder function can be altered in CD patients. In this review, we specifically analyze and summarize the main pathophysiological aspects and clinical evidence of gallbladder dysfunction in CD patients, in order to discuss the potential medical complications and clinical research gaps. In addition to some perturbations of bile composition, CD patients can develop gallbladder dysmotility, which mainly expresses with an impaired emptying during the digestive phase. The main pathophysiological determinant is a perturbation of cholecystokinin secretion by the specific duodenal enteroendocrine cells in response to the appropriate nutrient stimulation in CD patients. This situation appears to be reversible with a gluten-free diet in most cases. Despite this gallbladder impairment, CD patients do not seem to be more predisposed to gallbladder complications, such as calculous and acalculous cholecystitis. However, very few clinical studies have actively investigated these clinical aspects, which may not be completely evidenced so far; alternatively, the substantial improvements in the last two decades regarding CD diagnosis, which have reduced the diagnostic delay (and related dietary treatment), may have lessened the potential clinical consequences of CD-related gallbladder dysfunction. Specific clinical studies focused on these aspects are needed for a better understanding of the clinical implications of gallbladder alterations in CD patients.

Gallbladder motility in children with celiac disease before and after gluten-free diet

Background

Gallbladder (GB) hypomotility has been reported in adults with celiac disease (CD), but there is no literature on GB dysfunction in children with CD. We aimed to study GB motility in children with CD, before and after a gluten-free diet (GFD), using ultrasonography (USG) and technetium-99 labeled mebrofenin hepatobiliary scintigraphy (HBS).

Methods

Children with newly diagnosed CD were enrolled and evaluated for GB ejection fraction (GBEF) using HBS and USG. Those with reduced GBEF on initial HBS were again evaluated after 6 months of strict GFD and the results were compared.

Results

Of the 50 children with CD (mean age 9±2.1 years, 54% boys), 16% (n=8) had a low GBEF at baseline (19±13%). These children had a significantly greater delay in diagnosis compared to those with normal GBEF (6.5±2.0 vs. 2.3±1.2 years, P<0.001). A significant improvement in GBEF was noted on HBS post GFD (74±12%1 vs. 9±13%, P<0.001). GBEF also improved significantly as assessed by USG parameters after GFD (P<0.001). The fasting GB volume decreased (5.7±1.4 vs. 10.2±2.6, P=0.002), with a significant improvement in percentage postprandial GB volume change (52±10.5% vs. 24±16.5%, P=0.007) compared to baseline pre-GFD values. Orocecal transit time was also increased in children with reduced GBEF.

Conclusions

GB function is impaired in at least 16% of children with CD at diagnosis and is reversible with GFD. GB dysfunction is significantly associated with a delayed diagnosis and may be a part of general gastrointestinal dysmotility.

Gastrointestinal dysfunction in neuroinflammatory diseases: Multiple sclerosis, neuromyelitis optica, acute autonomic ganglionopathy and related conditions

Disorders of the nervous system can produce a variety of gastrointestinal (GI) dysfunctions. Among these, lesions in various brain structures can cause appetite loss (hypothalamus), decreased peristalsis (presumably the basal ganglia, pontine defecation center/Barrington's nucleus), decreased abdominal strain (presumably parabrachial nucleus/Kolliker-Fuse nucleus) and hiccupping and vomiting (area postrema/dorsal vagal complex). In addition, decreased peristalsis with/without loss of bowel sensation can be caused by lesions of the spinal long tracts and the intermediolateral nucleus or of the peripheral nerves and myenteric plexus. Recently, neural diseases of inflammatory etiology, particularly those affecting the PNS, are being recognized to contribute to GI dysfunction. Here, we review neuroinflammatory diseases that potentially cause GI dysfunction. Among such CNS diseases are multiple sclerosis, neuromyelitis optica spectrum disorder, myelin oligodendrocyte glycoprotein associated disorder, and autoimmune encephalitis. Peripheral nervous system diseases impacting the gut include Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, acute sensory-autonomic neuropathy/acute motor-sensory-autonomic neuropathy, acute autonomic ganglionopathy, myasthenia gravis and acute autonomic neuropathy with paraneoplastic syndrome. Finally, collagen diseases, such as Sjogren syndrome and systemic sclerosis, and celiac disease affect both CNS and PNS. These neuro-associated GI dysfunctions may predate or present concurrently with brain, spinal cord or peripheral nerve dysfunction. Such patients may visit gastroenterologists or physicians first, before the neurological diagnosis is made. Therefore, awareness of these phenomena among general practitioners and collaboration between gastroenterologists and neurologists are highly recommended in order for their early diagnosis and optimal management, as well as for systematic documentation of their presentations and treatment.

Association of heart rate variability, blood pressure variability, and baroreflex sensitivity with gastric motility at rest and during cold pressor test

AIM

To understand the mutual interaction of gastric motility and autonomic functions, the present study evaluated the association of heart rate variability (HRV), blood pressure variability (BPV), and baroreflex sensitivity (BRS) with gastric motility assessed by electrogastrography (EGG) at rest and during CPT and explored the effect of sympathetic activation by cold pressor test (CPT) on gastric motility.

BACKGROUND

The autonomic nervous system has a significant influence on gastrointestinal motility. HRV is commonly employed to assess the functions of the autonomic nervous system. BPV and BRS are relatively newer techniques and give a more holistic picture of autonomic functions along with the short-term regulation of blood pressure (BP).

METHODS

In fourteen young, healthy subjects, gastric motility was assessed by EGG. Beat-to-beat BP and lead II ECG were recorded to assess HRV, BPV, and BRS. BPV and BRS parameters were calculated for systolic, mean, and diastolic BP. Parameters of HRV and BPV were calculated for time and frequency domains. BRS was calculated by sequence and spectral methods.

RESULTS

Significant increases in diastolic BP (p = <0.0001) and EGG frequency (p = 0.0229) were observed during CPT. Significant correlations were observed between EGG frequencies and many of the HRV, BPV, and BRS parameters. The correlation coefficient was found to be highest between total power of HRV and EGG frequencies during baseline (p = 0.0107, r = -0.6571) and during CPT (p = 0.0059, r = -0.6935).

CONCLUSION

EGG frequency can be decreased by an acute increase in sympathetic activity induced by CPT. The novel findings are the significant correlations between many of the HRV, BPV, and BRS parameters and EGG frequency.

Irritable Bowel Syndrome and Gluten-Related Disorders

Background: Irritable bowel syndrome (IBS) is frequently associated with celiac disease (CD) and nonceliac gluten/wheat sensitivity (NCGS/NCWS), but epidemiological and pathophysiological aspects are still unclear. Furthermore, a gluten-free diet (GFD) can positively influence IBS symptoms. Methods: A comprehensive online search for IBS related to CD, NCGS and GFD was made using the Pubmed, Medline and Cochrane databases. Results: Although a systematic screening for CD in IBS is not recommended, CD prevalence can be increased in diarrhea-predominant IBS patients. On the other hand, IBS symptoms can be persistent in treated CD patients, and their prevalence tends to decrease on a GFD. IBS symptoms may overlap and be similar to those associated to nonceliac gluten and/or wheat sensitivity. Increased gut permeability could explain the gluten/wheat effects in IBS patients. Finally, a GFD could improve symptoms in a subgroup of IBS patients. Conclusions: The possible interplay between IBS and gluten-related disorders represents a scientifically and clinically challenging issue. Further studies are needed to confirm these data and better clarify the involved pathophysiological mechanisms.

Self-Reported Non-Celiac Gluten Sensitivity in Brazil: Translation, Cultural Adaptation, and Validation of Italian Questionnaire

This study aimed to translate, culturally adapt, validate, and apply a questionnaire to the Brazilian non-celiac gluten sensitive (NCGS) population. We also aimed to estimate the prevalence of symptoms which affect Brazilian NCGS. The Brazilian Portuguese version of the NCGS questionnaire was developed according to revised international guidelines. Five-hundred-and-fourty-three participants responded the NCGS questionnaire. We evaluated the reproducibility and validity of the questionnaire which presents valid measures of reproducibility. This is the first specific self-reported validated questionnaire for NCGS patients in Brazilian Portuguese, and the first nationwide characterization of self-reported NCGS in Brazilian adults. Most respondents were female (92.3%), and the main intestinal symptoms reported were bloating and abdominal pain. The most frequent extraintestinal symptoms were lack of wellbeing, tiredness, and depression. We expect that the present study will provide a picture of Brazilian individuals with suspected NCGS, which could help health professionals and governmental institutions in developing effective strategies to improve the treatment and diagnosis of Brazilian NCGS.