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Raju SA, Shiha MG, Penny HA. Monitoring coeliac disease in 2024, time to change practice? Curr Opin Gastroenterol 2024; 40:190-195. [PMID: 38547329 DOI: 10.1097/mog.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW Persistent villous atrophy is associated with morbidity in coeliac disease and most commonly due to ongoing gluten ingestion. Current methods for assessing gluten exposure and persisting villous atrophy include dietary questionnaires and repeat duodenal biopsy, which have limited accuracy or are invasive. This review discusses adjunctive and/or novel tests that could be used to overcome these challenges. RECENT FINDINGS Small bowel capsule endoscopy is well tolerated and helps to evaluate for persisting villous atrophy and importantly, complications associated with coeliac disease. Testing for urinary and/or stool gluten immunogenic peptides may help identify recent gluten exposure, but further studies are still warranted to evaluate the accuracy and applicability of this approach. Measuring spikes in circulating Interleukin-2 following gluten challenge has shown promise for coeliac disease diagnosis, and thus may serve as a useful confirmatory test in those with persisting symptoms but provides no information on mucosal inflammation. No specific gut microbial signature has been identified in coeliac disease; however, studies have shown a reduced microbial diversity in active disease, which with future refinement may prove clinically useful. SUMMARY There is no evidence to support alternative methods for assessing persisting villous atrophy in coeliac disease over performing an up-to-date duodenal biopsy. Monitoring for adherence to a gluten-free diet remains clinically challenging and should be a priority for future research.
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Affiliation(s)
- Suneil A Raju
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
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Penny HA, Aziz I, Lam C. Mast cell activation and nutritional disorders in patients with hypermobility. Curr Opin Gastroenterol 2024; 40:225-232. [PMID: 38393310 DOI: 10.1097/mog.0000000000001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
PURPOSE OF REVIEW Individuals with joint hypermobility disorders are increasingly referred to gastroenterology services for support with the investigation and management of gastrointestinal complaints. Individuals can present with a myriad of complex coexisting diagnoses, the inter-relationship of which is unclear. This review discusses the proposed association between hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD) with disorders of mast cell activation and provides an overview of gastrointestinal symptoms and nutritional outcomes in this patient cohort. RECENT FINDINGS It is unclear whether a true association between hEDS/HSD and mast cell activation disorders exists. There is a high prevalence of nonspecific gastrointestinal symptoms in individuals with hEDS/HSD and patients may be at risk of macro-nutrient and micro-nutrient deficiencies, although the current evidence base is limited. SUMMARY We advocate a pragmatic approach to the investigation and management of gastrointestinal symptoms in patients with hEDS/HSD. This centres on excluding organic pathology, discussing the overlap with disorders of gut-brain interactions, trialling evidence-based therapies targeting individual symptoms, and supporting nutritional deficiencies where present via the least invasive approach. Engagement with a broad multidisciplinary team is also important to support the holistic needs of this patient cohort.
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Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Imran Aziz
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Ching Lam
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals Foundation Trust
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
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Shiha MG, Nandi N, Raju SA, Wild G, Cross SS, Singh P, Elli L, Makharia GK, Sanders DS, Penny HA. Accuracy of the No-Biopsy Approach for the Diagnosis of Celiac Disease in Adults: A Systematic Review and Meta-Analysis. Gastroenterology 2024; 166:620-630. [PMID: 38176661 DOI: 10.1053/j.gastro.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 11/26/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND & AIMS Current international guidelines recommend duodenal biopsies to confirm the diagnosis of celiac disease in adult patients. However, growing evidence suggests that immunoglobulin A (IgA) anti-tissue transglutaminase (tTg) antibody levels ≥10 times the upper limit of normal (ULN) can accurately predict celiac disease, eliminating the need for biopsy. We performed a systematic review and meta-analysis to evaluate the accuracy of the no-biopsy approach to confirm the diagnosis of celiac disease in adults. METHODS We systematically searched MEDLINE, EMBASE, Cochrane Library, and Web of Science from January 1998 to October 2023 for studies reporting the sensitivity and specificity of IgA-tTG ≥10×ULN against duodenal biopsies (Marsh grade ≥2) in adults with suspected celiac disease. We used a bivariate random effects model to calculate the summary estimates of sensitivity, specificity, and positive and negative likelihood ratios. The positive and negative likelihood ratios were used to calculate the positive predictive value of the no-biopsy approach across different pretest probabilities of celiac disease. The methodological quality of the included studies was evaluated using the QUADAS-2 tool. This study was registered with PROSPERO, number CRD42023398812. RESULTS A total of 18 studies comprising 12,103 participants from 15 countries were included. The pooled prevalence of biopsy-proven celiac disease in the included studies was 62% (95% confidence interval [CI], 40%-83%). The proportion of patients with IgA-tTG ≥10×ULN was 32% (95% CI, 24%-40%). The summary sensitivity of IgA-tTG ≥10×ULN was 51% (95% CI, 42%-60%), and the summary specificity was 100% (95% CI, 98%-100%). The area under the summary receiver operating characteristic curve was 0.83 (95% CI, 0.77 - 0.89). The positive predictive value of the no-biopsy approach to identify patients with celiac disease was 65%, 88%, 95%, and 99% if celiac disease prevalence was 1%, 4%, 10%, and 40%, respectively. Between-study heterogeneity was moderate (I2 =30.3%), and additional sensitivity analyses did not significantly alter our findings. Only 1 study had a low risk of bias across all domains. CONCLUSION The results of this meta-analysis suggest that selected adult patients with IgA-tTG ≥10×ULN and a moderate to high pretest probability of celiac disease could be diagnosed without undergoing invasive endoscopy and duodenal biopsy.
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Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom.
| | - Nicoletta Nandi
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Graeme Wild
- Department of Immunology, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Simon S Cross
- Department of Histopathology, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Prashant Singh
- Division of Gastroenterology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
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Raju SA, Greenaway EA, Schiepatti A, Arpa G, Vecchione N, Jian CLA, Grobler C, Maregatti M, Green O, Bowker-Howell FJ, Shiha MG, Penny HA, Cross SS, Ciacci C, Rostami K, Ahmadipour S, Moradi A, Rostami-Nejad M, Biagi F, Volta U, Fiorentino M, Lebwohl B, Green PH, Lewis S, Molina-Infante J, Mata-Romero P, Vaira V, Elli L, Soykan I, Ensari A, Sanders DS. New entity of adult ultra-short coeliac disease: the first international cohort and case-control study. Gut 2024:gutjnl-2023-330913. [PMID: 38499339 DOI: 10.1136/gutjnl-2023-330913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 02/27/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Ultra-short coeliac disease (USCD) is defined as villous atrophy only present in the duodenal bulb (D1) with concurrent positive coeliac serology. We present the first, multicentre, international study of patients with USCD. METHODS Patients with USCD were identified from 10 tertiary hospitals (6 from Europe, 2 from Asia, 1 from North America and 1 from Australasia) and compared with age-matched and sex-matched patients with conventional coeliac disease. FINDINGS Patients with USCD (n=137, median age 27 years, IQR 21-43 years; 73% female) were younger than those with conventional coeliac disease (27 vs 38 years, respectively, p<0.001). Immunoglobulin A-tissue transglutaminase (IgA-tTG) titres at index gastroscopy were lower in patients with USCD versus conventional coeliac disease (1.8×upper limit of normal (ULN) (IQR 1.1-5.9) vs 12.6×ULN (IQR 3.3-18.3), p<0.001).Patients with USCD had the same number of symptoms overall (median 3 (IQR 2-4) vs 3 (IQR 1-4), p=0.875). Patients with USCD experienced less iron deficiency (41.8% vs 22.4%, p=0.006).Both USCD and conventional coeliac disease had the same intraepithelial lymphocytes immunophenotype staining pattern; positive for CD3 and CD8, but not CD4.At follow-up having commenced a gluten-free diet (GFD) (median of 1181 days IQR: 440-2160 days) both USCD and the age-matched and sex-matched controls experienced a similar reduction in IgA-tTG titres (0.5 ULN (IQR 0.2-1.4) vs 0.7 ULN (IQR 0.2-2.6), p=0.312). 95.7% of patients with USCD reported a clinical improvement in their symptoms. INTERPRETATION Patients with USCD are younger, have a similar symptomatic burden and benefit from a GFD. This study endorses the recommendation of D1 sampling as part of the endoscopic coeliac disease diagnostic workup.
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Affiliation(s)
- Suneil A Raju
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, Faculty of Medicine and Population Health, The University of Sheffield Medical School, Sheffield, UK
| | - Emily A Greenaway
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, Faculty of Medicine and Population Health, The University of Sheffield Medical School, Sheffield, UK
| | - Annalisa Schiepatti
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - Giovanni Arpa
- Department of Molecular Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
- Anatomical Pathology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Nicoletta Vecchione
- Department of Medicine, Surgery, Dentistry, University of Salerno, Fisciano, Italy
| | - Chao LA Jian
- Gastroenterology and Hepatology, MidCentral District Health Board, Palmerston North, New Zealand
| | | | - Margherita Maregatti
- Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Olivia Green
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, Faculty of Medicine and Population Health, The University of Sheffield Medical School, Sheffield, UK
| | - Freya J Bowker-Howell
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, Faculty of Medicine and Population Health, The University of Sheffield Medical School, Sheffield, UK
| | - Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, Faculty of Medicine and Population Health, The University of Sheffield Medical School, Sheffield, UK
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, Faculty of Medicine and Population Health, The University of Sheffield Medical School, Sheffield, UK
| | - Simon S Cross
- Division of Clinical Medicine, Faculty of Medicine and Population Health, The University of Sheffield Medical School, Sheffield, UK
| | - Carolina Ciacci
- Department of Medicine, Surgery, Dentistry, University of Salerno, Fisciano, Italy
| | - Kamran Rostami
- Department of Gastroenterology, MidCentral District Health Board, Palmerston North, New Zealand
| | - Shokoufeh Ahmadipour
- Hepatitis ResearcH Center, Lorestan University of Medical Sciences, Khoram-Abad, Iran (the Islamic Republic of)
| | - Afshin Moradi
- School of Medicine, Department of Pathology, Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Mohammad Rostami-Nejad
- Celiac Disease and Gluten Related Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Federico Biagi
- Gastroenterology Unit of Pavia Institute, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Benjamin Lebwohl
- Celiac Disease Center, Columbia University Medical Center, New York, New York, USA
| | - Peter Hr Green
- Celiac Disease Center, Columbia University Medical Center, New York, New York, USA
| | - Suzanne Lewis
- Celiac Disease Center, Columbia University Medical Center, New York, New York, USA
| | - Javier Molina-Infante
- Department of Gastroenterology, Centro de Investigación Biomédica en Red, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de Caceres, Caceres, Spain
| | - Pilar Mata-Romero
- Department of Gastroenterology, Hospital Universitario de Caceres, Caceres, Spain
| | - Valentina Vaira
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy
- Division of Pathology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irfan Soykan
- Department of Gastroenterology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Arzu Ensari
- Department of Pathology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, Faculty of Medicine and Population Health, The University of Sheffield Medical School, Sheffield, UK
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Shiha MG, Raju SA, Penny HA, Sanders DS. Non-coeliac gluten sensitivity: from Salerno to Rome. Lancet Gastroenterol Hepatol 2024; 9:94-95. [PMID: 38040020 DOI: 10.1016/s2468-1253(23)00358-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK.
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Shiha MG, Nandi N, Hutchinson AJ, Raju SA, Tai FWD, Elli L, Penny HA, Sanders DS. Cost-benefits and environmental impact of the no-biopsy approach for the diagnosis of coeliac disease in adults. Frontline Gastroenterol 2023; 15:95-98. [PMID: 38420132 PMCID: PMC10897647 DOI: 10.1136/flgastro-2023-102494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/04/2023] [Indexed: 03/02/2024] Open
Abstract
Objective Recent evidence suggests that adult patients with IgA tissue transglutaminase levels of ≥10× the upper limit of normal could be accurately diagnosed with coeliac disease without undergoing endoscopy and biopsy. We aimed to evaluate the cost-benefits and the environmental impact of implementing the no-biopsy approach for diagnosing coeliac disease in clinical practice. Design We calculated the overall direct and indirect costs of the conventional serology-biopsy approach and the no-biopsy approach for the diagnosis of coeliac disease based on the national average unit costs and the Office of National Statistics data. We further estimated the environmental impact of avoiding endoscopy based on the estimated greenhouse gas emissions from endoscopy. Results Approximately 3000 endoscopies for suspected coeliac disease could be avoided each year in the UK. Implementing the no-biopsy approach for the diagnosis of coeliac disease in adults could save the National Health Service over £2.5 million in direct and indirect costs per annum and reduce endoscopy carbon footprint by 87 tonnes of CO2 per year, equivalent to greenhouse gas emissions from driving 222 875 miles, carbon emissions from charging over 10 million smartphones and the carbon sequestrated by 1438 trees grown for 10 years. Conclusion The implementation of this non-invasive green approach could be an essential first step in the 'Reduce' strategy advocated by the British Society of Gastroenterology and other international endoscopy societies for sustainable endoscopy practice.
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Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - Nicoletta Nandi
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Pathophysiology and Organ Transplantation, University of Milan, Milano, Italy
| | - Andrew J Hutchinson
- Department of Electronic and Electrical Engineering, The University of Sheffield, Sheffield, UK
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - Foong Way David Tai
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - David Surendran Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
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Shiha MG, Nandi N, Oka P, Raju SA, Penny HA, Hopper AD, Elli L, Sanders DS. Narrow-band imaging for optical diagnosis of duodenal villous atrophy in patients with suspected coeliac disease: A systematic review and meta-analysis. Dig Liver Dis 2023:S1590-8658(23)00904-0. [PMID: 37666682 DOI: 10.1016/j.dld.2023.08.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/13/2023] [Accepted: 08/20/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Narrow-band imaging (NBI) is a readily accessible imaging technique that enhances mucosal visualisation, allowing for a more accurate assessment of duodenal villi. However, its role in the diagnosis of coeliac disease (CD) in clinical practice remains limited. METHODS We systematically searched several databases in June 2023 for studies evaluating the diagnostic accuracy of NBI for detecting duodenal villous atrophy (VA) in patients with suspected CD. We calculated the summary sensitivity, specificity, and likelihood ratios using a bivariate random-effects model. The study followed PRISMA guidelines and was registered at PROSPERO (CRD42023428266). RESULTS A total of 6 studies with 540 participants were included in the meta-analysis. The summary sensitivity of NBI to detect VA was 93% (95% CI, 81% - 98%), and the summary specificity was 95% (95% CI, 92% - 98%). The area under the summary receiver operating characteristic curve was 0.98 (95% CI, 96 - 99). The positive and negative predictive values of NBI were 94% (95% CI, 92% - 97%) and 92% (95% CI, 90% - 94%), respectively. CONCLUSION NBI is an accurate non-invasive tool for identifying and excluding duodenal VA in patients with suspected CD. Further studies using a validated classification are needed to determine the optimal role of NBI in the diagnostic algorithm for CD.
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Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK.
| | - Nicoletta Nandi
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Department of Pathophysiology and Organ Transplantation, University of Milan, Milan, Italy
| | - Priya Oka
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Andrew D Hopper
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Luca Elli
- Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK; Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
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Rej A, Penny HA. Current evidence for dietary therapies in irritable bowel syndrome. Curr Opin Gastroenterol 2023; 39:219-226. [PMID: 36976876 DOI: 10.1097/mog.0000000000000930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
PURPOSE OF REVIEW Diet appears to trigger symptoms in the majority of individuals with irritable bowel syndrome (IBS) and is associated with a reduced quality of life. There has been a recent focus on the role of dietary therapies to manage individuals with IBS. The aim of this review is to discuss the utility of traditional dietary advice (TDA), low-FODMAP diet (LFD) and gluten-free diet (GFD) in IBS. RECENT FINDINGS Several recent randomized controlled trials (RCTs) have been published demonstrating the efficacy of the LFD and GFD in IBS, with the evidence base for TDA being predominantly based on clinical experience, with emerging RCTs evaluating TDA. Only one RCT has been published to date comparing TDA, LFD and GFD head to head, with no difference noted between diets in terms of efficacy. However, TDA has been noted to be more patient-friendly and is commonly implemented as a first-line dietary therapy. SUMMARY Dietary therapies have been demonstrated to improve symptoms in patients with IBS. In view of insufficient evidence to recommend one diet over another currently, specialist dietetic input in conjunction with patient preference is required to determine implementation of dietary therapies. Novel methods of dietetic delivery are required in view of the lack of dietetic provision to deliver these therapies.
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Affiliation(s)
- Anupam Rej
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield
- Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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Abstract
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.
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Affiliation(s)
- Mohamed G Shiha
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust
- Academic Unit of Gastroenterology, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Suneil A Raju
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust
- Academic Unit of Gastroenterology, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Reena Sidhu
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust
- Academic Unit of Gastroenterology, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Hugo A Penny
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust
- Academic Unit of Gastroenterology, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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Schinnerling K, Penny HA, Soto JA, Melo-Gonzalez F. Immune Responses at Host Barriers and Their Importance in Systemic Autoimmune Diseases. Adv Exp Med Biol 2023; 1408:3-24. [PMID: 37093419 DOI: 10.1007/978-3-031-26163-3_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Host barriers such as the skin, the lung mucosa, the intestinal mucosa and the oral cavity are crucial at preventing contact with potential threats and are populated by a diverse population of innate and adaptive immune cells. Alterations in antigen recognition driven by genetic and environmental factors can lead to autoimmune systemic diseases such rheumatoid arthritis, systemic lupus erythematosus and food allergy. Here we review how different immune cells residing at epithelial barriers, host-derived signals and environmental signals are involved in the initiation and progression of autoimmune responses in these diseases. We discuss how regulation of innate responses at these barriers and the influence of environmental factors such as the microbiota can affect the susceptibility to develop local and systemic autoimmune responses particularly in the cases of food allergy, systemic lupus erythematosus and rheumatoid arthritis. Induction of pathogenic autoreactive immune responses at host barriers in these diseases can contribute to the initiation and progression of their pathogenesis.
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Affiliation(s)
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
- Department of Infection, Immunity and Cardiovascular Diseases, University of Sheffield, Sheffield, UK
| | - Jorge A Soto
- Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile.
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile.
| | - Felipe Melo-Gonzalez
- Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile.
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile.
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Penny HA, Domingues RG, Krauss MZ, Melo-Gonzalez F, Lawson MA, Dickson S, Parkinson J, Hurry M, Purse C, Jegham E, Godinho-Silva C, Rendas M, Veiga-Fernandes H, Bechtold DA, Grencis RK, Toellner KM, Waisman A, Swann JR, Gibbs JE, Hepworth MR. Rhythmicity of intestinal IgA responses confers oscillatory commensal microbiota mutualism. Sci Immunol 2022; 7:eabk2541. [PMID: 36054336 PMCID: PMC7613662 DOI: 10.1126/sciimmunol.abk2541] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Interactions between the mammalian host and commensal microbiota are enforced through a range of immune responses that confer metabolic benefits and promote tissue health and homeostasis. Immunoglobulin A (IgA) responses directly determine the composition of commensal species that colonize the intestinal tract but require substantial metabolic resources to fuel antibody production by tissue-resident plasma cells. Here, we demonstrate that IgA responses are subject to diurnal regulation over the course of a circadian day. Specifically, the magnitude of IgA secretion, as well as the transcriptome of intestinal IgA+ plasma cells, was found to exhibit rhythmicity. Oscillatory IgA responses were found to be entrained by time of feeding and were also found to be in part coordinated by the plasma cell-intrinsic circadian clock via deletion of the master clock gene Arntl. Moreover, reciprocal interactions between the host and microbiota dictated oscillatory dynamics among the commensal microbial community and its associated transcriptional and metabolic activity in an IgA-dependent manner. Together, our findings suggest that circadian networks comprising intestinal IgA, diet, and the microbiota converge to align circadian biology in the intestinal tract and to ensure host-microbial mutualism.
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Affiliation(s)
- Hugo A. Penny
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - Rita G. Domingues
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - Maria Z. Krauss
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - Felipe Melo-Gonzalez
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - Melissa A.E. Lawson
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - Suzanna Dickson
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - James Parkinson
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - Madeleine Hurry
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - Catherine Purse
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - Emna Jegham
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
| | | | - Miguel Rendas
- Champalimaud Research, Champalimaud Centre for the Unknown, Lisbon, 1400-038, Portugal
| | | | - David A. Bechtold
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - Richard K. Grencis
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
- Wellcome Centre for Cell Matrix Research, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - Kai-Michael Toellner
- Institute of Immunology and Immunotherapy, College of Medical & Dental Sciences, Medical School, University of Birmingham, Birmingham, B15 2TT, UK
| | - Ari Waisman
- Institute for Molecular Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Jonathan R. Swann
- School of Human Development and Health, Faculty of Medicine, University of Southampton, SO16 6YD, Southampton, United Kingdom
| | - Julie E. Gibbs
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, M13 9PL, Manchester, United Kingdom
| | - Matthew R. Hepworth
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, M13 9PL, Manchester, United Kingdom
- School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, United Kingdom
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Penny HA, Rej A, Baggus EMR, Coleman SH, Ward R, Wild G, Bouma G, Trott N, Snowden JA, Wright J, Cross SS, Hadjivassiliou M, Sanders DS. Non-Responsive and Refractory Coeliac Disease: Experience from the NHS England National Centre. Nutrients 2022; 14:nu14132776. [PMID: 35807956 PMCID: PMC9268848 DOI: 10.3390/nu14132776] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 02/04/2023] Open
Abstract
We characterised the aetiology of non-responsive coeliac disease (NRCD) and provided contemporary mortality data in refractory coeliac disease (RCD) from our centre. We also measured urine gluten immunogenic peptides (GIPs) in patients with established RCD1 to evaluate gluten exposure in these individuals. Methods: This was a longitudinal cohort study conducted in Sheffield, UK. Between 1998 and 2019, we evaluated 285 adult (≥16 years) patients with NRCD or RCD. Patients with established RCD1 and persisting mucosal inflammation and/or ongoing symptoms provided three urine samples for GIP analysis. Results: The most common cause of NRCD across the cohort was gluten exposure (72/285; 25.3%). RCD accounted for 65/285 patients (22.8%), 54/65 patients (83.1%) had RCD1 and 11/65 patients (16.9%) had RCD2. The estimated 5-year survival was 90% for RCD1 and 58% for RCD2 (p = 0.016). A total of 36/54 (66.7%) patients with RCD1 underwent urinary GIP testing and 17/36 (47.2%) had at least one positive urinary GIP test. Conclusion: The contemporary mortality data in RCD2 remains poor; patients with suspected RCD2 should be referred to a recognised national centre for consideration of novel therapies. The high frequency of urinary GIP positivity suggests that gluten exposure may be common in RCD1; further studies with matched controls are warranted to assess this further.
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Affiliation(s)
- Hugo A. Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
- Correspondence: (H.A.P.); (D.S.S.); Tel.: +44-0114-271-1900 (H.A.P. & D.S.S.)
| | - Anupam Rej
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Elisabeth M. R. Baggus
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Sarah. H. Coleman
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Rosalie Ward
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Graeme Wild
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Gerd Bouma
- Department of Gastroenterology, Vrije Universiteit Medical Center, 1117 Amsterdam, The Netherlands;
| | - Nick Trott
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - John A. Snowden
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield S10 2JF, UK; (J.A.S.); (J.W.)
| | - Josh Wright
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield S10 2JF, UK; (J.A.S.); (J.W.)
| | - Simon S. Cross
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
| | - Marios Hadjivassiliou
- Department of Neurology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield S10 2JF, UK;
| | - David S. Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK; (A.R.); (E.M.R.B.); (S.H.C.); (R.W.); (G.W.); (N.T.); (S.S.C.)
- Correspondence: (H.A.P.); (D.S.S.); Tel.: +44-0114-271-1900 (H.A.P. & D.S.S.)
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Raju SA, Sanders DS, Penny HA. Coeliac Disease and Probiotics: Clinicians Need to Provide the Evidence Base for this Unmet Need. J Gastrointestin Liver Dis 2021; 30:423-426. [PMID: 34941975 DOI: 10.15403/jgld-4092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Suneil A Raju
- Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK.
| | - David S Sanders
- Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Hugo A Penny
- Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
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Penny HA, Raju SA, Lau MS, Marks LJS, Baggus EMR, Bai JC, Bassotti G, Bontkes HJ, Carroccio A, Danciu M, Derakhshan MH, Ensari A, Ganji A, Green PHR, Johnson MW, Ishaq S, Lebwohl B, Levene A, Maxim R, Mohaghegh Shalmani H, Rostami-Nejad M, Rowlands D, Spiridon IA, Srivastava A, Volta U, Villanacci V, Wild G, Cross SS, Rostami K, Sanders DS. Accuracy of a no-biopsy approach for the diagnosis of coeliac disease across different adult cohorts. Gut 2021; 70:876-883. [PMID: 33139268 PMCID: PMC8040155 DOI: 10.1136/gutjnl-2020-320913] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/29/2020] [Accepted: 07/18/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to determine the predictive capacity and diagnostic yield of a 10-fold increase in serum IgA antitissue transglutaminase (tTG) antibody levels for detecting small intestinal injury diagnostic of coeliac disease (CD) in adult patients. DESIGN The study comprised three adult cohorts. Cohort 1: 740 patients assessed in the specialist CD clinic at a UK centre; cohort 2: 532 patients with low suspicion for CD referred for upper GI endoscopy at a UK centre; cohort 3: 145 patients with raised tTG titres from multiple international sites. Marsh 3 histology was used as a reference standard against which we determined the performance characteristics of an IgA tTG titre of ≥10×ULN for a diagnosis of CD. RESULTS Cohort 1: the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 54.0%, 90.0%, 98.7% and 12.5%, respectively. Cohort 2: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 50.0%, 100.0%, 100.0% and 98.3%, respectively. Cohort 3: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 30.0%, 83.0%, 95.2% and 9.5%, respectively. CONCLUSION Our results show that IgA tTG titres of ≥10×ULN have a strong predictive value at identifying adults with intestinal changes diagnostic of CD. This study supports the use of a no-biopsy approach for the diagnosis of adult CD.
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Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Michelle S Lau
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Lauren JS Marks
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Elisabeth MR Baggus
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Julio C Bai
- Medicine, Gastroenterology Hospital 'Dr C Bonorino Udaondo', Buenos Aires, Argentina
| | - Gabrio Bassotti
- Gastroenterology & Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - Hetty J Bontkes
- Department Clinical Chemistry, Amsterdam Gastroenterology and Metabolism and Infection and Immunity Institutes, Amsterdam UMC, Amsterdam, The Netherlands
| | - Antonio Carroccio
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Mihai Danciu
- Pathology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | | | - Arzu Ensari
- Department of Pathology, Ankara University Medical School, Ankara, Turkey
| | - Azita Ganji
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Matt W Johnson
- Gastroenterology, Luton and Dunstable Hospital NHS Foundation Trust, Luton, UK
| | - Sauid Ishaq
- Department of Gastroenterology, Dudley Group NHS Foundation Trust, Birmingham City University, Birmingham, UK
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Adam Levene
- Gastroenterology, Luton and Dunstable Hospital NHS Foundation Trust, Luton, UK
| | - Roxana Maxim
- Gastroenterology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | - Hamid Mohaghegh Shalmani
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Rostami-Nejad
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - David Rowlands
- Department of Gastroenterology, Queen Elizabeth II Hospital, Hertfordshire, UK
| | - Irene A Spiridon
- Pathology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | | | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Graeme Wild
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Simon S Cross
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Kamran Rostami
- Department of Gastroenterology, MidCentral District Health Board, Palmerston North, New Zealand
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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Taylor MA, Blanshard RJ, Naylor G, Penny HA, Mooney PD, Sanders DS. Do gastroenterologists have medical inertia towards coeliac disease? A UK multicentre secondary care study. BMJ Open Gastroenterol 2021; 8:e000544. [PMID: 33455912 PMCID: PMC7813426 DOI: 10.1136/bmjgast-2020-000544] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/06/2020] [Accepted: 12/16/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE This study aimed to assess if there is secondary care medical inertia towards coeliac disease (CD). DESIGN Group (1): Time from primary care presentation to diagnostic endoscopy was quantified in 151 adult patients with a positive endomysial antibody test and compared with 92 adult patients with histologically proven inflammatory bowel disease (IBD). Group (2): Across four hospitals, duodenal biopsy reports for suspected CD were reviewed (n=1423). Group (3): Clinical complexity was compared between known CD (n=102) and IBD (n=99) patients at their respective follow-up clinic appointments. Group (4): 50 gastroenterologists were questioned about their perspective on CD and IBD. RESULTS Group (1): Suspected coeliac patients waited significantly longer for diagnostic endoscopy following referral (48.5 (28-89) days) than suspected patients with IBD (34.5 (18-70) days; p=0.003). Group (2): 1423 patients underwent diagnostic endoscopy for possible CD, with only 40.0% meeting guidelines to take four biopsies. Increased diagnosis of CD occurred if guidelines were followed (10.1% vs 4.6% p<0.0001). 12.4% of newly diagnosed CD patients had at least one non-diagnostic gastroscopy in the 5 years prior to diagnosis. Group (4): 32.0% of gastroenterologists failed to identify that CD has greater prevalence in adults than IBD. Moreover, 36.0% of gastroenterologists felt that doctors were not required for the management of CD. CONCLUSION Prolonged waiting times for endoscopy and inadequacies in biopsy technique were demonstrated suggesting medical inertia towards CD. However, this has to be balanced against rationalising care accordingly. A Coeliac UK National Patient Charter may standardise care across the UK.
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Affiliation(s)
| | - Rebecca J Blanshard
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, Sheffield, UK
- The University of Sheffield, Sheffield, Sheffield, UK
| | - Gregory Naylor
- Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, Derbyshire, UK
| | - Hugo A Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, Sheffield, UK
| | - Peter D Mooney
- Department of Gastroenterology, Northern General Hospital, Sheffield, Sheffield, UK
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - David S Sanders
- The University of Sheffield Medical School, Sheffield, UK
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, Sheffield, UK
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Adu-Tei S, Penny HA, El-Fekhi M, Ruse C, Sanders DS. Healthcare professionals' attitudes towards PEG tube feeding in advanced dementia: time to engage with a wide clinical audience? MINERVA GASTROENTERO 2020; 65:246-248. [PMID: 31617698 DOI: 10.23736/s1121-421x.19.02588-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sebastian Adu-Tei
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK -
| | - Hugo A Penny
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK.,Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Mansour El-Fekhi
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Charlotte Ruse
- Department of Geriatrics, Northern General Hospital, Sheffield, UK
| | - David S Sanders
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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Abstract
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.
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Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Penny HA, Baggus EMR, Rej A, Snowden JA, Sanders DS. Non-Responsive Coeliac Disease: A Comprehensive Review from the NHS England National Centre for Refractory Coeliac Disease. Nutrients 2020; 12:E216. [PMID: 31947666 PMCID: PMC7019917 DOI: 10.3390/nu12010216] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/06/2020] [Accepted: 01/09/2020] [Indexed: 02/06/2023] Open
Abstract
Coeliac disease is a common small intestinal enteropathy which manifests following ingestion of gluten in genetically susceptible individuals. Since gluten was identified as the driving factor in coeliac disease, the gluten-free diet (GFD) has remained the mainstay of treatment. While most individuals will display improvement in symptoms and signs of coeliac disease following institution of the GFD, up to 30% will continue to experience symptoms and/or have persisting intestinal inflammation. These individuals can be classified as having non-responsive coeliac disease (NRCD), which may be associated with dietary indiscretion, slow healing, refractory coeliac disease, and/or an alternative condition. The purpose of this review is to provide an overview of the causes of NRCD in adults, highlight a systematic approach to investigate these patients, and appraise the latest management aspects of this subset of coeliac disease.
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Affiliation(s)
- Hugo A. Penny
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
- Lydia Becker Institute of Inflammation and Immunology, University of Manchester, Manchester M13 9PL, UK
| | - Elisabeth M. R. Baggus
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
| | - Anupam Rej
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
| | - John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK;
| | - David S. Sanders
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield S10 2TN, UK; (H.A.P.); (E.M.R.B.); (A.R.)
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Penny HA, Kurien M, Fowler G, Wardle D, Azmy I, Sanders DS. Grit and tidiness: could what we know help us achieve success? Postgrad Med J 2017; 94:246-247. [PMID: 29133378 DOI: 10.1136/postgradmedj-2017-135376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2017] [Indexed: 11/04/2022]
Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Matthew Kurien
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - George Fowler
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - David Wardle
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Iman Azmy
- Department of Breast Surgery, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, UK
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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Penny HA, Aziz I, Ferrar M, Atkinson J, Hoggard N, Hadjivassiliou M, West JN, Sanders DS. PWE-055 Coeliac Disease is More Common in Subjects with Postural Orthostatic Tachycardia Syndrome Compared to Healthy Controls. Gut 2016. [DOI: 10.1136/gutjnl-2016-312388.301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Penny HA, Kurien M, Wong E, Ahmed R, Ejenavi E, Lau M, Romaya C, Gohar F, Dear KL, Kapur K, Hoeroldt B, Lobo AJ, Sanders DS. Changing trends in the UK management of upper GI bleeding: is there evidence of reduced UK training experience? Frontline Gastroenterol 2016; 7:67-72. [PMID: 28839837 PMCID: PMC5369461 DOI: 10.1136/flgastro-2014-100537] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 01/11/2015] [Accepted: 01/12/2015] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate UK trainee experience in endoscopy for acute upper gastrointestinal bleeding (AUGIB). METHODS Data was prospectively collected from all patients presenting to South Yorkshire Hospitals with AUGIB from September 2011 to December 2011 and compared with data from 1996. Concurrently, all gastroenterology trainees registered with the British Society of Gastroenterology were invited to respond to a web-based questionnaire regarding their experience in AUGIB management. RESULTS 77% (589/766) of the patient cohort underwent endoscopy for AUGIB; 15% (90/589) were performed by trainees. 7.2% (9/125) of the out of hours endoscopy case load was performed by trainees; all were low-risk or medium-risk cases (pre-endoscopy Rockall score ≤4). During the study period, dual therapy was delivered by a trainee on only four occasions. Comparison with the 1996 cohort demonstrated a marked reduction in the number of trainee performed endoscopies (76% vs 15%; p<0.001). Questionnaires were returned by 51% (245/478) of British Society of Gastroenterology trainees. 81% (198/245) thought that <10% of the gastroscopies they had performed involved therapeutic intervention. 23% (57/245) felt they would not be competent in AUGIB endoscopy by completion of specialty training. CONCLUSIONS This study demonstrates the decline over time in trainee experience in AUGIB endoscopy. It also highlights a lack of trainee exposure to more challenging cases, out of hours endoscopy and therapeutic procedures. Furthermore, trainees are concerned that a level of competency may not be attained during specialty training. We advocate reviewing UK endoscopic training provision for AUGIB to ensure that experienced endoscopists are produced to meet future service needs.
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Affiliation(s)
- H A Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - M Kurien
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - E Wong
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - R Ahmed
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - E Ejenavi
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - M Lau
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - C Romaya
- British Society of Gastroenterology, London, UK
| | - F Gohar
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - K L Dear
- Department of Gastroenterology, Chesterfield Hospital, Chesterfield, UK
| | - K Kapur
- Department of Gastroenterology, Barnsley Hospital, Barnsley, UK
| | - B Hoeroldt
- Department of Gastroenterology, Rotherham Hospital, Rotherham, UK
| | - A J Lobo
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - D S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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Penny HA, Leeds JS, Kurien M, Averginos A, Hopper AD, Hadjivassiliou M, Tesfaye S, Sanders DS. The relationship between inflammatory bowel disease and type 1 diabetes mellitus: a study of relative prevalence in comparison with population controls. J Gastrointestin Liver Dis 2015; 24:125-126. [PMID: 25822445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Hugo A Penny
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK.
| | - John S Leeds
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Matthew Kurien
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | | | - Andrew D Hopper
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | | | - Solomon Tesfaye
- Department of Diabetes, Royal Hallamshire Hospital, Sheffield, UK
| | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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