Celiac disease

Association between celiac disease and fibromyalgia and their severity: a cross-sectional study

Background

Fibromyalgia (FMS) is a common musculoskeletal disorder with many causes. People with fibromyalgia often have the same symptoms as people with celiac disease (CD). Demonstration of the coordination and frequency of FMS and CD is important for effective treatment.

Methods

This is a single center cross-sectional clinical study. The study included 60 patients who were diagnosed with CD by the Gastroenterology Clinic based on American College of Gastroenterology (ACG) criteria. Patients were also asked to complete the Widespread Pain Index (WPI), Symptom Severity Scale (SSS), and Fibromyalgia Impact Questionnaire (FIQ) to diagnose fibromyalgia and assess its severity. The results were used to analyze the frequency of concomitance and relationship between the two diseases.

Results

The relationship between the clinical types of CD and the presence of fibromyalgia was insignificant. Analysis of the relationship between the pathologic typing of biopsy and fibromyalgia frequency was insignificant. Those with antibodies more frequently met criteria for fibromyalgia (P = 0.04, P = 0.04, respectively).

Conclusions

Presence of clinical extraintestinal manifestations in patients with CD should lead clinicians to consider FMS as a possible diagnosis. This points to the importance for clinicians in all subspecialties to be aware of the various symptoms and diseases associated with FMS.

A Deep Learning-Based Approach to Estimate Paneth Cell Granule Area in Celiac Disease

CONTEXT.—

Changes in Paneth cell numbers can be associated with chronic inflammatory diseases of the gastrointestinal tract. So far, no consensus has been achieved on the number of Paneth cells and their relevance to celiac disease (CD).

OBJECTIVES.—

To compare crypt and Paneth cell granule areas between patients with CD and those without CD (non-CD) using an artificial intelligence-based solution.

DESIGN.—

Hematoxylin-eosin-stained sections of duodenal biopsies from 349 patients at the McGill University Health Centre were analyzed. Of these, 185 had a history of CD and 164 were controls. Slides were digitized, and NoCodeSeg, a code-free workflow using open-source software (QuPath, DeepMIB), was implemented to train deep learning models to segment crypts and Paneth cell granules. The total area of the entire analyzed tissue, epithelium, crypts, and Paneth cell granules was documented for all slides, and comparisons were performed.

RESULTS.—

A mean intersection-over-union score of 88.76% and 91.30% was achieved for crypt areas and Paneth cell granule segmentations, respectively. On normalization to total tissue area, the crypt to total tissue area in CD was increased and the Paneth cell granule area to total tissue area decreased when compared to non-CD controls.

CONCLUSIONS.—

Crypt hyperplasia was confirmed in CD compared to non-CD controls. The area of Paneth cell granules, an indirect measure of Paneth cell function, decreased with increasing severity of CD. More importantly, our study analyzed complete hematoxylin-eosin slide sections using an efficient and easy to use coding-free artificial intelligence workflow.

Psychological, Psychiatric, and Organic Brain Manifestations of Celiac Disease

INTRODUCTION

Celiac disease is an autoimmune condition that affects approximately 1% of the population worldwide. Although its main impact often concerns the small intestine, resulting in villous atrophy and nutrient malabsorption, it can also cause systemic manifestations, particularly when undiagnosed or left untreated.

METHOD

Attention is directed to the possible psychological, psychiatric, and organic brain manifestations of celiac disease. Specific topics related to the influence and risk of such manifestations with respect to celiac disease are defined and discussed. Overall, eighteen main topics are considered, sifted from over 500 references.

RESULTS

The most often studied topics were found to be the effect on quality of life, organic brain dysfunction and ataxia, epilepsy, Down syndrome, generalized psychological disorders, eating dysfunction, depression, and schizophrenia. For most every topic, although many studies report a connection to celiac disease, there are often one or more contrary studies and opinions. A bibliographic analysis of the cited articles was also done. There has been a sharp increase in interest in this research since 1990. Recently published articles tend to receive more referencing, up to as many as 15 citations per year, suggesting an increasing impact of the topics. The number of manuscript pages per article has also tended to increase, up to as many as 12 pages. The impact factor of the publishing journal has remained level over the years.

CONCLUSION

This compendium may be useful in developing a consensus regarding psychological, psychiatric, and organic brain manifestations that can occur in celiac disease and for determining the best direction for ongoing research focus.

Serological Screening for Celiac Disease and Gastrointestinal Absorption Disorders in Patients with Autoimmune Endocrine Diseases

Celiac disease (CD) accompanying autoimmune endocrine diseases (AED) is generally asymptomatic. This study aimed to evaluate the frequency of clinically overt or silent CD in patients diagnosed with autoimmune endocrinopathy and the clinical effects of silent CD in these endocrinopathies. The study included 166 patients with known or newly diagnosed mono-/polyglandular AED and 90 age- and gender-matched healthy controls. The patients were classified into four groups: type 1 diabetes mellitus (DM) (n=44), Hashimoto's thyroiditis (HT) (n=68), Addison's disease (AD) (n=17), and autoimmune polyglandular syndrome (APS) (n=37). All subjects were serologically screened for tissue transglutaminase antibody (tTG) IgA and IgG. In addition, to evaluate the possible systemic consequences of CD, serum parathormone (PTH), 25-hydroxicholecalsiferol (25-OH-Vit D), vitamin B12, folic acid, iron, iron-binding capacity (IBC), and ferritin levels were measured. In the total series, 193 (75.4%) individuals were females, and 63 (24.6%) were males. TTG IgA antibody positivity was found in 23 among 166 patients, while no positivity was encountered in the healthy control group. The highest rates of positive tTg IgA frequency were detected in AD, with 29.4% (5/17). Serum 25-OH-Vit D, vitamin B12, folic acid, iron, and ferritin levels were significantly lower in AEDs compared to controls (p<0.001), and the lowest these parameters were detected in patients with AD. The serologic CD prevalence is higher in autoimmune mono-/and polyglandular endocrine diseases than in the control group. The data support recommends regular screening for CD in all patients with AEDs.

Novel Therapies for Celiac Disease: A Clinical Review Article

Celiac disease is emerging as an autoimmune disorder with increasing prevalence and incidence. The mean age of presentation is also increasing with the passage of time. The delay in diagnosis is partly attributable to the asymptomatic state in which most patients present. The diagnosis of the disease is primarily based on biopsy, but serology can also be included for possible screening purposes. Although the primary management strategy is to eliminate gluten from the diet of such patients; however, compliance with the diet and follow-up to detect healing might be difficult to maintain. Therefore, there is a need to investigate further management therapies that can be easily administered and monitored. The aim of the review is to discuss the epidemiology, clinical presentation, and novel therapies being investigated for celiac disease.

Unique nutritional features that distinguish Amaranthus cruentus L. and Chenopodium quinoa Willd seeds

Univariate (Analysis of Variance_ANOVA) and multivariate (Principal Component Analysis (PCA) and Canonical Discriminant Analysis (CDA)) analyses were performed in order to classify and authenticate the seeds from different varieties of quinoa (Chenopodium quinoa Will.), and amaranth (Amaranthus cruentus L.). The univariate analysis showed differences between species for sucrose, K, Ca, unsaturated fatty acids, and the ω6/ω3 ratio. Nevertheless, to strengthen this classification, a PCA was applied separating the samples in 2 groups; group 1, formed by quinoa seeds, presented higher contents of margaroleic, eicosadienoic, behenic, erucic, linolenic, linoleic, and gadoleic acids, proteins, sucrose, and total sugars. Group 2, formed by amaranth seeds, showed positive values for Mn, Mg, Fe, P, Zn, Ca, fiber, glucose, and ω6/ω3 ratio. Furthermore, the CDA models developed resulted in a probability of event of 100% when classifying the samples in the groups quinoa or amaranth, highlighting the good sensitivity of the models used.

Gluten-induced Neurocognitive Impairment: Results of a Nationwide Study

GOALS

This study aimed to understand the neurocognitive symptoms associated with gluten exposure in individuals with self-reported celiac disease (CD) and nonceliac gluten sensitivity (NCGS).

BACKGROUND

While gluten-induced neurocognitive impairment (GINI; eg, "celiac fog" or "brain fog") is commonly described by individuals with CD and NCGS, there are little data regarding the prevalence and symptoms associated with these experiences.

STUDY

A 9-question online survey was accessed by 1396 individuals (1143 with CD; 253 with NCGS). Forced choice and free-response questions were asked of participants to obtain a description of neurocognitive symptoms experienced after gluten ingestion. Free-response answers were coded using a coding structure developed based on the Health-Related Quality of Life Instrument.

RESULTS

The majority of survey participants (89% of CD and 95% of NCGS) reported having GINI symptoms. When describing symptoms, the most common word descriptors for both groups were difficulty concentrating, forgetfulness, and grogginess. Timing of symptoms, including onset and symptom peak, were similar across the 2 groups. Coding of free responses found the most common references were to cognitive, physical, psychological, and overall quality of life impacts.

CONCLUSIONS

This survey suggests that GINI is common and may be severe in both individuals with CD and NCGS. Cognitive impairment and decline in physical functioning may be similar to that occurring in other illnesses, such as lupus. Clinical follow-up with both individuals with CD and NCGS should include assessment of GINI symptoms. Further research is warranted, including the development of a patient-reported outcome measure including neurocognitive effects of gluten exposure.

The effects of whey protein fibrils on the linear and non-linear rheological properties of a gluten-free dough

The increasing awareness of the celiac disease, an autoimmune disorder caused by the consumption of products containing gluten, has led to a growing interest in the development of gluten-free bakery products. In this study, whey protein fibrils (WPFs) were incorporated to mimic the fibrous network of gluten. The rheological properties and microstructure of the developed gluten-free doughs were evaluated and compared with gluten doughs. Protein fibrils were prepared by heating a whey protein isolate (WPI) solution at 80°C in an acidic environment with low salt concentration, and then the fibril lengths were adjusted by leveling up the solution pH to 3.5 and 7. The dimensions of the fibrils were measured by atomic force microscopy (AFM). Rice and potato starches were mixed with fibrils, WPI, gluten, or without protein, to form different doughs for further investigation. Shear tests, including stress sweep, frequency sweep, and creep recovery, were performed to study the viscoelastic properties of doughs under small or large deformation. The strain-hardening properties of doughs under biaxial extension were studied by the lubricated squeezing flow method. The microstructure of the doughs was characterized by cryo-scanning electron microscopy (cryo-SEM). Compared with doughs prepared with WPI and no proteins, doughs incorporating fibrils showed comparable linear viscoelasticity to gluten dough tested with stress sweep, frequency sweep, and creep recovery in the linear viscoelastic region. More differences between the protein fibril doughs were revealed in the rheological properties in the non-linear region. Creep recovery parameters, such as compliance, elastic moduli during the creep, and recovery stages of gluten dough, were like those of WPF pH7 dough, but significantly different from those of the WPF pH3.5 dough. Strain-hardening properties were found in the WPF pH7 dough, although not in WPF pH3.5 dough. Microstructural characterization showed that both fibrils prepared with the different conditions formed a continuous protein phase for the improvement of dough cohesiveness, but the structure of the phase was different between the two fibrils. To summarize, whey protein fibril at pH 7 seemed to have the potential of being used as an ingredient with similar functions to gluten in gluten-free bakery products.

THE RELATIONSHIP BETWEEN GLUTEN ENTEROPATHY AND NAIL CAPILEROSCOPY FINDINGS AND DISEASE ACTIVATION

Objective: Nailfold Videocapilloroscopy (NVC) is an examination method that is used as an aid in the diagnosis, follow-up, and treatment strategy of rheumatic diseases such as systemic sclerosis, systemic lupus erythematosus, rheumatoid arthritis, and gives an idea about microcirculation by examining the vascular bed. It is a cheap, easily applicable, and quickly accessible method. Because of these features, we aimed to use the NVC method in patients with Gluten Enteropathy (GE) to determine whether this method will be a helpful technique in the diagnosis, activation decision, remission follow-up, and treatment strategy in patients with GE. Methods: In this study, 67 patients diagnosed with GE (n=35 disease-active group (AGE), n=32 disease-related remission group (RGE), and control group (CG)-27 healthy people whose diagnosis of GE was ruled out were included in this study. Group and CG were divided into ten parameters in capillary pathologies (capillary density loss, dilated capillary, giant capillary, microhemorrhage, avascular area, tortuosity, branched capillary, disorganization, extravasation, angiogenesis). They were divided into two groups as RGE and compared with the results obtained from NVC measurements Results: When patients diagnosed with GE and CG were evaluated in terms of capillary disorder with NVC, While all of the patients with capillary disorders were in the GE group, no capillary disorders were found in the control group (p

Atypical hematological manifestation of celiac disease: A case report of aplastic anemia in a 2-year-old child and review of the literature

INTRODUCTION

Celiac disease typically presents with symptoms of malabsorption, but extraintestinal manifestations are increasingly reported. Aplastic anemia as the mode of celiac disease presentation is extremely rare in children.

CASE PRESENTATION

We report a 2-year-old boy who presented with loose stools, loss of appetite, and bicytopenia with severe aregenerative normocytic anemia. Investigations, including bone marrow aspirate and biopsy, revealed aplastic anemia. Screening for malabsorption showed increased plasma concentrations of anti-transglutaminase and anti-gliadin antibodies. A duodenal biopsy confirmed the histologic features of celiac disease. The child received a packed red cell transfusion and was started on a gluten-free diet, with a very good prognosis and normalization of both his blood and histological parameters. To the best of our knowledge, our report is the sixth pediatric case in the literature.

CONCLUSION

Screening for celiac disease should be performed in children with unexplained hematological abnormalities such as aplastic anemia with or without gastrointestinal symptoms.

The Healthy Gluten-Free Diet: Practical Tips to Prevent Metabolic Disorders and Nutritional Deficiencies in Celiac Patients

The gluten-free diet (GFD) is the cornerstone treatment for coeliac disease (CD). However, a healthy GFD is more complex than the only exclusion of gluten-containing foods. Most celiac patients do not receive nutritional advice and tend to consume industrial gluten-free products (GFPs), which often lack fiber, vitamins, and other micronutrients while being rich in saturated fats and refined sugars. This review focuses on the main potential metabolic disorders and nutritional deficiencies in CD patients at diagnosis and dissects the main nutritional and metabolic issues due to a non-balanced GFD. Nutritional tips to achieve an adequate dietary approach in CD are provided. We also compared the main nutritional components of naturally gluten-free cereals (including pseudocereals) to give an exhaustive overview of the possible healthy alternatives to processed GFPs. Clinicians and dietitians should be systematically involved in the diagnosis of CD to monitor the appropriateness of GFD and the patient’s nutritional status over time.

Coeliac disease presenting atypically: A much wider spectrum

Atypical coeliac disease in young children is frequently missed when it presents atypically as non-gastrointestinal presentations to different specialties. There was a greater delay (54 months) in establishing the diagnosis in those with atypical coeliac disease (p < 0.001). No difference was observed in the mode of delivery or duration of breast feeding, but significant difference was observed between gestational age at birth (p < 0.001). Most cases showed stunted growth and underweight. Irritability, anaemia, rickets, dermatitis herpetiformis, alopecia and intussusception were other common predictors of atypical coeliac disease. Because of a myriad spectrum of non-gastrointestinal symptoms, at any age with diverse presentation, a high index of suspicion is therefore required.

Small Intestinal Adenocarcinoma in a Patient With Celiac Disease

Celiac disease (CD) is a systemic immune-mediated disorder against gluten, leading to an autoantibody response causing damage to the small intestinal mucosa. CD has been associated with gastrointestinal malignancies, most commonly gastrointestinal lymphoma. Rare malignancies have also been reported, such as small intestinal adenocarcinoma. In this report, we present a case of a 91-year-old male with a history of CD, noncompliant with a gluten-free diet, who presented with weight loss, abdominal pain, and gastrointestinal bleeding secondary to a newly discovered adenocarcinoma of the jejunum.

Fecal microRNAs as Innovative Biomarkers of Intestinal Diseases and Effective Players in Host-Microbiome Interactions

Over the past decade, short non-coding microRNAs (miRNAs), including circulating and fecal miRNAs have emerged as important modulators of various cellular processes by regulating the expression of target genes. Recent studies revealed the role of miRNAs as powerful biomarkers in disease diagnosis and for the development of innovative therapeutic applications in several human conditions, including intestinal diseases. In this review, we explored the literature and summarized the role of identified dysregulated fecal miRNAs in intestinal diseases, with particular focus on colorectal cancer (CRC) and celiac disease (CD). The aim of this review is to highlight one fascinating aspect of fecal miRNA function related to gut microbiota shaping and bacterial metabolism influencing. The role of miRNAs as "messenger" molecules for inter kingdom communications will be analyzed to highlight their role in the complex host-bacteria interactions. Moreover, whether fecal miRNAs could open up new perspectives to develop novel suitable biomarkers for disease detection and innovative therapeutic approaches to restore microbiota balance will be discussed.

DNA damage, oxidative stress, and inflammation in children with celiac disease

The objective of this study was to evaluate the level of genomic instability in patients with celiac disease and to establish a relationship between inflammation, oxidative stress, and DNA damage in these patients. Myeloperoxidase (MPO) activity, adenosine deaminase, nitric oxide (NOx), thiobarbituric acid, catalase (CAT), superoxide dismutase (SOD), glutathione peroxidase (GPx), and DNA damage were evaluated in peripheral blood samples from 47 celiac disease patients and 31 controls. Patients with celiac disease presented higher levels of DNA damage in comparison to controls (p=0.023). This difference was also observed for markers of oxidative stress, such as CAT (p=0.011) and SOD (p=0.013), and inflammatory markers such as MPO (p < 0.001) and NOx (p=0.009). Positive correlations were found between DNA damage levels and the values of CAT (r=0.405; p=0.009) and SOD (r=0.516; p < 0.001). Positive correlations were also found between GPx and NOx (r=0.349; p=0.030) and MPO and NOx (r=0.239; p=0.039). CAT and NOx showed a negative correlation (r= −0.315; p=0.042). In conclusion, intestinal inflammation can have systemic effects, causing an imbalance between oxidant and antioxidant markers, which may promote increased levels of DNA damage.

Pseudocereal grains: Nutritional value, health benefits and current applications for the development of gluten-free foods

Nowadays, consumers are more conscious of the environmental and nutritional benefits of foods. Pseudocereals grains, edible seeds belonging to dicotyledonous plant species, are becoming a current trend in human diets as gluten-free (GF) grains with excellent nutritional and nutraceutical value. Pseudocereals are a good source of starch, fiber, proteins, minerals, vitamins, and phytochemicals such as saponins, polyphenols, phytosterols, phytosteroids, and betalains with potential health benefits. The present review aims to summarize the nutritional quality and phytochemical profile of the three main pseudocereal grains: quinoa, amaranth and buckwheat. In addition, current evidence about their health benefits in animal models and human studies is also provided in detail. Based on the accumulating research supporting the inclusion of pseudocereals grains in the diet of celiac persons, this review discusses the recent advances in their application for the development of new GF products. Future directions for a wider cultivation and commercial exploitation of these crops are also highlighted.

Concepts and Instruments for Patient-Reported Outcome Assessment in Celiac Disease: Literature Review and Experts' Perspectives

BACKGROUND

In diseases where there is a large subjective component, such as celiac disease (CD), patient reported-outcomes (PRO) endpoints are highly relevant. However, there is a gap in knowledge about which PRO endpoints and instruments should be used for clinical trials for treatment of celiac disease.

OBJECTIVES

To identify patient-centered symptom, impact, and health-related quality of life (HRQoL) concepts in CD and relevant PRO instruments, and to gather expert input on concepts and instruments to inform selection of PRO endpoints for use in clinical trials of new CD treatments.

METHODS

A targeted literature review was conducted to identify symptom, impact, and HRQoL concepts, including those captured in PROs further reviewed against U.S. Food and Drug Administration standards for development and validation as endpoints. US and European clinicians, payers, and a patient advocate (n = 21) were interviewed to assess the identified concepts' relative importance in measuring treatment benefit and to gauge the value of potential PROs as endpoints for market access/reimbursement.

RESULTS

Thirty-four published studies were identified: 27 elucidated patient-centered concepts and 7 detailed the development or validation of PRO instruments. The Celiac Disease Symptom Diary and Celiac Disease Patient Reported Outcome instrument were deemed most appropriate for use as endpoints; however, each had limitations related to conceptual coverage, evidence for measurement properties, and feasibility for use in clinical trials. Experts reported gastrointestinal symptoms as most important to treat, with extra-intestinal symptoms burdensome from the patient perspective as well. Payers emphasized measuring both frequency and severity of symptoms and targeting patients nonresponsive to the gluten-free diet for treatment.

CONCLUSIONS

With emerging treatment options for CD, further work is needed to operationalize PRO symptom endpoints that are meaningful to patients, valued by payers, and acceptable to regulators in demonstrating efficacy.

Effect of amaranth and quinoa seed flour on rheological and physicochemical properties of goat meat nuggets

An attempt was made through the present study to prepare gluten free goat meat nuggets by replacing refined wheat flour from product formulation with healthy, dietary fibre rich amaranth (A) and quinoa (Q) flour at different levels. A total of five different treatments viz., AI (1.5% amaranth), AII (3% amaranth), QI (1.5% quinoa) and QII (3% quinoa) were prepared. The physicochemical, colour, texture, sensory and rheological properties of these pseudocereal-added products were evaluated against control (3% refined wheat flour). Emulsion stability of meat batter was significantly affected (P < 0.05) due to addition of amaranth flour (1.5% and 3%) and quinoa (3%). Treatment groups AII and QI had significantly low (P < 0.05) moisture content with respect to control while the amount of fat content showed a reverse trend. Addition of amaranth and quinoa significantly increased (P < 0.05) the dietary fibre in meat products. Rheology of meat batter was affected by types and level of pseudocereal incorporation. Treatment AII had low (P < 0.05) hunter colour lightness value, whereas redness value was low for treatment QI. Effect of added amaranth and quinoa flour was observed on the textural parameters like adhesiveness, cohesiveness, gumminess and chewiness. High scores for almost all the sensory parameters were recorded in pseudocereal-added meat products. Though, all the products were very much acceptable, product with 1.5% quinoa flour was found to have high (P < 0.05) overall acceptability score.

Lactic Fermentation as a Strategy to Improve the Nutritional and Functional Values of Pseudocereals

One of the greatest challenges is to reduce malnutrition worldwide while promoting sustainable agricultural and food systems. This is a daunting task due to the constant growth of the population and the increasing demands by consumers for functional foods with higher nutritional values. Cereal grains are the most important dietary energy source globally; wheat, rice, and maize currently provide about half of the dietary energy source of humankind. In addition, the increase of celiac patients worldwide has motivated the development of gluten-free foods using alternative flour types to wheat such as rice, corn, cassava, soybean, and pseudocereals (amaranth, quinoa, and buckwheat). Amaranth and quinoa have been cultivated since ancient times and were two of the major crops of the Pre-Colombian cultures in Latin- America. In recent years and due to their well-known high nutritional value and potential health benefits, these pseudocereals have received much attention as ideal candidates for gluten-free products. The importance of exploiting these grains for the elaboration of healthy and nutritious foods has forced food producers to develop novel adequate strategies for their processing. Fermentation is one of the most antique and economical methods of producing and preserving foods and can be easily employed for cereal processing. The nutritional and functional quality of pseudocereals can be improved by fermentation using Lactic Acid Bacteria (LAB). This review provides an overview on pseudocereal fermentation by LAB emphasizing the capacity of these bacteria to decrease antinutritional factors such as phytic acid, increase the functional value of phytochemicals such as phenolic compounds, and produce nutritional ingredients such as B-group vitamins. The numerous beneficial effects of lactic fermentation of pseudocereals can be exploited to design novel and healthier foods or grain ingredients destined to general population and especially to patients with coeliac disease.

Descriptive Study of the Different Tools Used to Evaluate the Adherence to a Gluten-Free Diet in Celiac Disease Patients

Celiac disease (CD) is a genetically conditioned autoimmune process that appears in susceptible people. It can affect people of any age, and slightly predominates in females. It has a fairly homogenous global distribution, with an average prevalence of 1⁻2%, the frequency having increased in recent decades. The only effective treatment is a strict and permanent gluten-free diet (GFD), although the level of compliance is poor, at about 50% of cases. To monitor the effectiveness of the GFD, several procedures involving various approaches are employed: (a) Periodic visits by expert Nutritionists; (b) Clinical follow-up; (c) Serological time controls of specific antibodies; (d) Serial endoscopies with collection of duodenal biopsies; (e) Use of structured questionnaires; and (f) Determination of gluten peptides derived from gluten in faeces and/or urine. All of these procedures are useful when applied, alone or in combination, depending on the cases. Some patients will only need to consult to their doctors, while others will require a multidisciplinary approach to assess their compliance with the GFD. In children, normalization of duodenal mucosa was achieved in 95% of cases within two years, while it is more delayed in adults, whose mucosa take longer time (3⁻5 years) to heal completely.

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.

Cutaneous and Mucosal Manifestations Associated with Celiac Disease

Celiac disease (CD) is an immune-mediated, gluten-induced enteropathy that affects predisposed individuals of all ages. Many patients with CD do not report gastrointestinal symptoms making it difficult to reach an early diagnosis. On the other hand, CD is related to a wide spectrum of extra-intestinal manifestations, with dermatitis herpetiformis (DH) being the best characterized. These associated conditions may be the clue to reaching the diagnosis of CD. Over the last few years, there have been multiple reports of the association between CD and several cutaneous manifestations that may improve with a gluten-free diet (GFD). The presence of some of these skin diseases, even in the absence of gastrointestinal symptoms, should give rise to an appropriate screening method for CD. The aim of this paper is to describe the different cutaneous manifestations that have been associated with CD and the possible mechanisms involved.

Oxidative and Antioxidative Status of Children with Celiac Disease Treated with a Gluten Free-Diet

Aims

Oxidative stress is a factor involved in the pathogenesis of celiac disease (CD), possibly affecting the course of the disease and celiac-related complications. We assessed the intensity of oxidative processes and the efficiency of antioxidant defense in children with celiac disease. Methods. Group I (n = 32) consisted of children with CD treated with a gluten-free diet, and group II (n = 24) consisted of healthy children on a traditional diet. Antioxidative and oxidative status was assessed by measurement of serum total antioxidant capacity (TAC), total oxidant capacity (TOC), and oxidized low-density lipoprotein (ox-LDL) and on the basis of oxidative stress index (OSI).

Results

There were no significant differences in serum TAC, TOC, ox-LDL, and OSI between children with CD and healthy children. Cluster analysis showed that the group of children with CD is not homogeneous in terms of serum TAC and TOC levels. About 50% of these children had TAC levels < 1.3 mmol/L and TOC levels > 0.35 mmol/L.

Conclusions

Strict adherence to a gluten-free diet by children with CD seems to be important for maintaining oxidative-antioxidant balance. However, further research is needed to identify factors potentially responsible for increased oxidative stress in some children with celiac disease despite adherence to a gluten-free diet.

The Gut-Kidney Axis: Putative Interconnections Between Gastrointestinal and Renal Disorders

Diabetic kidney disease (DKD) is a devastating condition associated with increased morbidity and premature mortality. The etiology of DKD is still largely unknown. However, the risk of DKD development and progression is most likely modulated by a combination of genetic and environmental factors. Patients with autoimmune diseases, like type 1 diabetes, inflammatory bowel disease, and celiac disease, share some genetic background. Furthermore, gastrointestinal disorders are associated with an increased risk of kidney disease, although the true mechanisms have still to be elucidated. Therefore, the principal aim of this review is to evaluate the impact of disturbances in the gastrointestinal tract on the development of renal disorders.

Digestive system in psoriasis: an update

Psoriasis is a chronic inflammatory immune-mediated disorder associated and often coexisting with many other immune-related clinical conditions including those affecting the gastrointestinal tract. Data obtained from the reviewed literature suggest an association between psoriasis and pathologies of the oral cavity, both psoriasis-specific lesions, as well as non-specific, such as geographic tongue or fissured tongue. These findings show the importance of thorough examination of oral mucosa in psoriatic patients. Inflammatory bowel diseases (IBD) are also linked with psoriasis. Crohn’s disease and ulcerative colitis share a common genetic background, inflammatory pathways and have an evident iatrogenic anti-TNF treatment link, necessitating dermatological or gastroenterological care in patients with IBD or psoriasis, respectively, as well as treatment adjusted to manifestations. The presence of celiac disease-specific antibodies in psoriatic patients and their correlation with the severity of the disease show the association between these disorders. The linking pathogenesis comprises vitamin D deficiency, immune pathway, genetic background and increase in the intestinal permeability, which suggests a potential benefit from gluten-free diet among psoriatic patients. The link between psoriasis and non-alcoholic fatty liver disease implies screening patients for components of metabolic syndrome and lifestyle changes necessity. Some studies indicate increased prevalence of cancer in patients with psoriasis, probably due to negative influence of skin lesion impact on lifestyle rather than the role of psoriasis in carcinogenesis. However, there are no sufficient data to exclude such an oncogenic hit, which is yet to be confirmed. Therefore, all psoriasis-associated comorbidities establish the importance of a multidisciplinary approach in the treatment of these patients.

Managing Celiac Disease for Women: Implications for the Primary Care Provider

Although many people have symptoms of celiac disease, it can take a while to diagnose. Villous atrophy may be present long before any gastrointestinal symptoms. An important point to acknowledge is that celiac disease could be identified earlier in some women with a positive family history. The disease also could be the cause of some women's reproductive problems. Primary care providers, using comprehensive history taking, are in the unique position to identify individuals who may have celiac disease, assist women in gaining knowledge about a gluten-free diet, order diagnostic testing, and refer to a gastroenterologist. The positive change in fertility with a simultaneous improvement of nutrient deficiencies shortly after adopting a gluten-free diet indicates a possible link between such nutrients and sex hormone function. High levels of homocysteine, which can negatively impact fertility, have also been linked to individuals with problems, such as celiac disease, that decrease vitamin B12 absorption. The purpose of this article is to review the literature and the evidence-based care guidelines for comprehensive screening, diagnostics, and pathophysiology of celiac disease, with a specific focus on the female reproductive system, anemia management, and gluten-free diet integration.

Diarrhea after allogeneic stem cell transplantation: beyond graft-versus-host disease

Diarrhea constitutes a frequent and often debilitating complication of allogeneic hematopoietic cell transplantation (alloHCT). Especially when accompanied by jaundice, skin rash, and symptoms of the upper gastrointestinal tract, diarrhea strongly suggests emergence of acute graft-versus-host disease (GvHD), which is a serious immune complication of the procedure, with possible fatal consequences. However, especially when diarrhea occurs as an isolated symptom, the other causes must be excluded before initiation of GvHD treatment with immune-suppressive drugs. In this article, a broad overview of the literature of different causes of diarrhea in the setting of alloHCT is provided, revealing causes and presentations different from those observed in the general population. We discuss gastrointestinal GvHD with a special focus on biomarkers, but also uncover underlying infectious: viral, bacterial, and parasitic as well as toxic causes of diarrhea. Finally, we suggest a practical algorithm of approach to patients with diarrhea after alloHCT, which may help to establish a proper diagnosis and initiate a causative treatment.

Screening for celiac disease in patients with eating disorders

PURPOSE

Celiac disease (CD) affects approximately 1% of the population, and although it remains largely underdiagnosed, can have considerable long-term morbidity. Common presenting symptoms include gastrointestinal complaints and weight loss, which are also symptoms seen in patients with eating disorders (EDs). Because of this overlap, and the importance of early diagnosis of CD and identifying possible complicating factors in patients with EDs, screening in our program has become part of an initial assessment during the past 4 years.

METHODS

A retrospective chart review of all patients ages 7-22 years seen in our Division of Adolescent Medicine for an ED evaluation from 2011 to 2014 were reviewed. Screening for CD was done with tissue transglutaminase IgA antibody (TTgAb) and anti-endomysial IgA antibody (aEAb). Immunoglobulin A (IgA) was also measured.

RESULTS

There were 1160 patients evaluated for an ED between 2011 and 2014, and 42.6% (494) were screened for CD during this time. Of those patients screened for CD the mean age was 16.0, compared to a mean age of 15.6 for those that were not screened, and 87.7% were female, compared to 84.7% of the unscreened group. Of the 494 screened, 10 (2%) screened positive with a TTgAb IgA EIA >20. Of the 10 who screened positive via blood test, four had biopsy confirmed CD via endoscopy, for an overall 0.8% prevalence in this cohort. Of the 457 patients who were also screened for IgA deficiency (92%), 5 (1.1%) had low IgA levels.

CONCLUSION

In this cohort of patients being evaluated for an ED, 0.8% had biopsy confirmed CD. This is similar to the reported prevalence in the general population, suggesting that routine screening of patients with EDs for CD is not indicated. We still need to be vigilant, however, for subtle symptoms that may indicate underlying CD in a small percentage of patients with EDs.