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Pivetta G, Coluccio C, Dilaghi E, Lahner E, Pilozzi E, Carabotti M, Corleto VD. In Elderly Anemic Patients without Endoscopic Signs of Bleeding Are Duodenal Biopsies Always Necessary to Rule Out Celiac Disease? Diagnostics (Basel) 2022; 12:diagnostics12030678. [PMID: 35328233 PMCID: PMC8947612 DOI: 10.3390/diagnostics12030678] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022] Open
Abstract
Iron-deficiency anemia in the elderly may be due to numerous gastrointestinal conditions. Anemia is frequent in celiac disease (CD); however, the use of routine duodenal biopsies, independently of age or serology, is debated. To determine the diagnostic yield of routine duodenal biopsies in adult and elderly patients with no bleeding anemia, a cross-sectional study analyzing 7968 gastroscopies (2017−2020) was performed; 744 were for anemia and 275 were excluded (GI bleeding or without duodenal biopsies). Of the 469 included patients, clinical, endoscopic, and histological features were analyzed in groups with or without histopathological changes in the duodenal mucosa (DM). Univariate/multivariate analyses were performed. Of the 469 patients, 41 (8.7%) had DM histopathological changes, 12 (2.6%) had CD, 26 (5.5%) had duodenal intraepithelial lymphocytosis (DIL), and 3 had (0.6%) other conditions. They were younger compared to patients with normal DM. DM histopathology was significantly inversely correlated with age group, with prevalences of 27%, 20%, 12.5%, 10%, and 2.5%, in the <40−50, 51−60, 61−70, 71−80, and >80-year age groups, respectively (p = 0.0010). Logistic-regression models showed that anemic patients aged >60, >70, or >80 years with endoscopically normal DM had a progressively three- to four-fold higher probability of having normal duodenal histology. In adults, anemic patients without bleeding, age and endoscopically normal DM are predictors of normal DM histology. In >70-year anemic patients, negligible DM pathology was found. The results suggest that routine duodenal biopsies are questionable in elderly anemic patients
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Affiliation(s)
- Giulia Pivetta
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy
| | - Chiara Coluccio
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy
| | - Emanuele Dilaghi
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy
| | - Edith Lahner
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy
| | - Emanuela Pilozzi
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University Sapienza, 00166 Rome, Italy
| | - Marilia Carabotti
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy
| | - Vito Domenico Corleto
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy
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Miglietta S, Borghini R, Relucenti M, Sorrentino V, Chen R, Li X, Fazi F, Donato G, Familiari G, Petrozza V, Picarelli A. New Insights into Intestinal Permeability in Irritable Bowel Syndrome-Like Disorders: Histological and Ultrastructural Findings of Duodenal Biopsies. Cells 2021; 10:2593. [PMID: 34685576 DOI: 10.3390/cells10102593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND AIM Diarrhea, abdominal pain, and bloating are frequent in irritable bowel syndrome (IBS)-like disorders, although little is known about their intestinal ultrastructural alterations. The aim of the present study was to study duodenal biopsies from IBS-like patients to find ultrastructural alterations. MATERIALS AND METHODS Study design: descriptive comparative pilot study. Thirty outpatients (9 male and 21 female; median age 37.7 years; range, 20 to 65 years) complaining of IBS-like symptoms were enrolled between January 2015 to May 2019 and were divided into 6 groups, each equally consisting of 5 patients: (A) untreated celiac disease (uCD); (B) treated celiac disease (tCD); (C) wheat allergy (WA); (D) Non-celiac gluten sensitivity (NCGS); (E) Nickel allergic contact mucositis (Ni ACM); (F) controls affected by GERD. Transmission electron microscopy (TEM) morphological characteristics were: microvilli length, intermicrovillar distance, junctional complexes (JC) gap width, autophagic bodies, apoptosis, altered mitochondria, lipid/chylomicron droplets, and mast cells. Regarding JC, we focused on tight junctions (TJ), adherens junctions (AJ), and desmosomes. RESULTS Major alterations in microvilli length and intermicrovillar distance have been observed in the subjects affected by uCD. Microvilli of tCD patients showed marked recovery after adequate GFD, although not comparable to controls. Intermediate microvillar alterations were instead observed in NCGS and Ni ACM, while characteristics of WA subjects appeared more similar to tCD. Regarding JC, TJ did not show significant differences between all groups studied, including controls. The AJ were significantly more dilated in all groups compared to controls, while no significant differences were found between the pathological groups. The distance between desmosomes was greater in uCD, NCGS, and Ni ACM than in tCD, WA, and controls. Finally, intracellular alterations have been detected in most of the groups studied although they seemed more unspecific. CONCLUSIONS TEM analysis confirmed damages to the intestinal barrier and defense mechanisms by enterocytes in IBS-like patients, probably linked to low-grade inflammation or adverse reactions triggered by food allergens, heavy metals, or other unknown. On the other hand, our study needs confirmation and further investigations with larger populations to facilitate diagnosis, therapy, and prevention of IBS-like disorders in the future.
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Ruiz-Carnicer Á, Garzón-Benavides M, Fombuena B, Segura V, García-Fernández F, Sobrino-Rodríguez S, Gómez-Izquierdo L, Montes-Cano MA, Rodríguez-Herrera A, Millán R, Rico MC, González-Naranjo C, Bozada-García JM, Díaz J, Coronel-Rodríguez C, Espín B, Romero-Gómez M, Cebolla Á, Sousa C, Comino I, Argüelles F, Pizarro Á. Negative predictive value of the repeated absence of gluten immunogenic peptides in the urine of treated celiac patients in predicting mucosal healing: new proposals for follow-up in celiac disease. Am J Clin Nutr 2020; 112:1240-1251. [PMID: 32692806 DOI: 10.1093/ajcn/nqaa188] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/15/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The treatment of celiac disease (CD) is a lifelong gluten-free diet (GFD). The current methods for monitoring GFD conformance, such as a dietary questionnaire or serology tests, may be inaccurate in detecting dietary transgressions, and duodenal biopsies are invasive, expensive, and not a routine monitoring technique. OBJECTIVES Our aim was to determine the clinical usefulness of urine gluten immunogenic peptides (GIP) as a biomarker monitoring GFD adherence in celiac patients and to evaluate the concordance of the results with the degree of mucosal damage. METHODS A prospective observational study was conducted involving 22 de novo CD patients, 77 celiac patients consuming a GFD, and 13 nonceliac subjects. On 3 d of the week, urine samples were collected and the GIP concentrations were tested. Simultaneously, anti-tissue transglutaminase antibodies, questionnaire results, clinical manifestations, and histological findings were analyzed. RESULTS Approximately 24% (18 of 76) of the celiac patients consuming a GFD exhibited Marsh II-III mucosal damage. Among this population, 94% (17 of 18) had detectable urine GIP; however, between 60% and 80% were asymptomatic and exhibited negative serology and appropriate GFD adherence based on the questionnaire. In contrast, 97% (31 of 32) of the celiac patients without duodenal damage had no detectable GIP. These results demonstrated the high sensitivity (94%) and negative predictive value (97%) of GIP measurements in relation to duodenal biopsy findings. In the de novo CD-diagnosed cohort, 82% (18 of 22) of patients had measurable amounts of GIP in the urine. CONCLUSIONS Determining GIP concentrations in several urine samples may be an especially convenient approach to assess recent gluten exposure in celiac patients and appears to accurately predict the absence of histological lesions. The introduction of GIP testing as an assessment technique for GFD adherence may help in ascertaining dietary compliance and to target the most suitable intervention during follow-up.
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Affiliation(s)
- Ángela Ruiz-Carnicer
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | - Marta Garzón-Benavides
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | - Blanca Fombuena
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | - Verónica Segura
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | | | | | | | - Marcos A Montes-Cano
- Institute of Biomedicine of Seville (IBiS), Seville, Spain; Faculty of Medicine, University of Seville, Seville, Spain
| | | | - Raquel Millán
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | - María C Rico
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | - Carmen González-Naranjo
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | - Juan M Bozada-García
- Endoscopy of Digestive Diseases Clinical Unit, Virgen del Rocío Hospital, Seville, Spain
| | - Jacobo Díaz
- Clinical Analysis Service, Hospital Universitario INGESA, Ceuta, Spain
| | | | - Beatriz Espín
- Pediatric, Gastroenterology, Hepatology and Nutrition Section, Virgen del Rocio Children's Hospital, Seville, Spain
| | - Manuel Romero-Gómez
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
| | | | - Carolina Sousa
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | - Isabel Comino
- Department of Microbiology and Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | - Federico Argüelles
- Digestive Diseases Clinical Unit, Virgen Macarena Hospital, Seville, Spain
| | - Ángeles Pizarro
- Digestive Disease Clinical Unit, Gastroenterology Division, Virgen del Rocío Hospital, Seville, Spain
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Rodrigo L, Pérez-Martinez I, Lauret-Braña E, Suárez-González A. Descriptive Study of the Different Tools Used to Evaluate the Adherence to a Gluten-Free Diet in Celiac Disease Patients. Nutrients 2018; 10:nu10111777. [PMID: 30453479 PMCID: PMC6267102 DOI: 10.3390/nu10111777] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/07/2018] [Accepted: 11/14/2018] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Luis Rodrigo
- Gastroenterology Unit, Hospital Universitario Central de Asturias (HUCA), CSIC, Avda. de Roma s/n, 33011 Oviedo, Spain.
| | - Isabel Pérez-Martinez
- Gastroenterology Unit, Hospital Universitario Central de Asturias (HUCA), CSIC, Avda. de Roma s/n, 33011 Oviedo, Spain.
| | - Eugenia Lauret-Braña
- Gastroenterology Unit, Hospital Universitario Central de Asturias (HUCA), CSIC, Avda. de Roma s/n, 33011 Oviedo, Spain.
| | - Adolfo Suárez-González
- Gastroenterology Unit, Hospital Universitario Central de Asturias (HUCA), CSIC, Avda. de Roma s/n, 33011 Oviedo, Spain.
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Greuter T, Schoedon G, Schneemann M. [Not Available]. Praxis (Bern 1994) 2016; 105:1175-1182. [PMID: 27705184 DOI: 10.1024/1661-8157/a002517] [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] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Zusammenfassung. Der Morbus Whipple ist eine seltene, chronisch verlaufende Systemerkrankung, die durch das ubiquitär vorhandene Bakterium Tropheryma whipplei verursacht wird und v.a. weisse Männer im mittleren Alter befällt. Die typischen Symptome sind Gelenkbeschwerden, Gewichtsverlust, Diarrhö und Abdominalschmerzen. In einem fortgeschrittenen Stadium kommt es zu neurologischen Komplikationen. Gelenkbeschwerden können den übrigen Symptomen um Jahre vorausgehen. Meist kann die Diagnose mittels Duodenalbiopsien gestellt werden. Die Therapie beinhaltet eine Induktionstherapie (i.d.R. Ceftriaxon) sowie eine Erhaltungstherapie (Trimethoprim-Sulfamethoxazol) für mindestens ein Jahr. Ohne Therapie verläuft die Erkrankung in der Regel tödlich.
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Affiliation(s)
- Thomas Greuter
- 1 Klinik und Poliklinik für Innere Medizin, Universitätsspital Zürich
| | - Gabriele Schoedon
- 1 Klinik und Poliklinik für Innere Medizin, Universitätsspital Zürich
| | - Markus Schneemann
- 1 Klinik und Poliklinik für Innere Medizin, Universitätsspital Zürich
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Zucchini L, Giusti D, Gatouillat G, Servettaz A, Tabary T, Barbe C, Pham BN. Interpretation of serological tests in the diagnosis of celiac disease: Anti-deamidated gliadin peptide antibodies revisited. Autoimmunity 2016; 49:414-420. [PMID: 27452003 DOI: 10.1080/08916934.2016.1203908] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Algorithms for celiac disease diagnosis provided by guidelines are based primarily on anti-tissue transglutaminase 2 (TG2) antibodies and/or anti-endomysium antibodies. The place of anti-deamidated gliadin peptide (DGP) antibodies is less well established. This study was designed to assess the clinical relevance of anti-DGP antibodies. Two thousand and twenty-six consecutive unselected patients systematically tested for anti-TG2, endomysium, gliadin, DGP antibodies and IgA dosage were investigated. The serological interpretation was assessed by analyzing the medical records of patients. From the 1984 newly investigated patients suspected of celiac disease, 10% had at least one celiac marker. Anti-TG2, anti-endomysium, anti-gliadin and anti-DGP antibodies were found in 1.1%, 0.6%, 6.8% and 4.1% of cases respectively, with different combinations. The diagnosis of celiac disease was retained in 0.45% of patients. When using the duodenal biopsies as a gold standard, analysis of the anti-DGP diagnosis performance showed that the specificity and the predictive positive value (PPV) were lower than that of the anti-TG2 assay. The combined detection of anti-TG2 and anti-DGP antibodies had a lower PPV than that of anti-TG2 and anti-endomysium antibodies (p = 0.04). When analyzing the contribution of anti-DGP antibodies as an additional marker to both anti-TG2 and anti-endomysium antibodies, the PPV of the three associated antibodies was shown to be significantly lower than the PPV of the both anti-TG2 and anti-endomysium antibodies (p = 0.04). As a conclusion, anti-DGP antibodies may not have the diagnosis value required as an additional screening test to anti-TG2 antibodies for identifying celiac disease patients in medical centers where anti-endomysium detection is available.
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Affiliation(s)
- Laure Zucchini
- a Department of Immunology , Robert Debré Hospital, Reims University Hospitals , Reims , France
| | - Delphine Giusti
- a Department of Immunology , Robert Debré Hospital, Reims University Hospitals , Reims , France.,b Faculty of Medicine , University of Reims Champagne-Ardenne , Reims , France
| | - Grégory Gatouillat
- a Department of Immunology , Robert Debré Hospital, Reims University Hospitals , Reims , France
| | - Amélie Servettaz
- c Department of Internal Medicine , Infectious Diseases, Clinical Immunology, Robert Debré Hospital, Reims University Hospitals , Reims , France , and
| | - Thierry Tabary
- a Department of Immunology , Robert Debré Hospital, Reims University Hospitals , Reims , France
| | - Coralie Barbe
- d Clinical Research Unit, Reims University Hospitals , Reims , France
| | - Bach-Nga Pham
- a Department of Immunology , Robert Debré Hospital, Reims University Hospitals , Reims , France.,b Faculty of Medicine , University of Reims Champagne-Ardenne , Reims , France
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Abstract
BACKGROUND An increase in intraepithelial lymphocytes (IELs) is mandatory for the histological diagnosis of coeliac disease (CD). Currently, duodenal biopsies are used almost exclusively to establish the diagnosis, yet published work continues to cite an upper limit of 40 lymphocytes/100 epithelial cells, a figure derived from jejunal biopsies over 30 years ago. AIM To establish the normal range for IEL counts in distal duodenal biopsies. MATERIALS/METHODS Twenty subjects (seven men, 13 women; median age, 34 years; range, 20-65) with a normal sugar permeability test and concurrent distal duodenal biopsies were identified. The number of IELs and epithelial cell nuclei in an uninterrupted length of surface (villous) epithelium (> 500 cells) was counted. An image analysis system was used to assess villous architecture by calculating the villous height to crypt depth ratio. RESULTS The range of IEL counts in 20 subjects was 1.8-26/100 villous epithelial cells, with a mean value of 11 and SD of 6.8. The mean villous to crypt ratio was 1.82 (SD, 0.38; range, 1.22-2.46). There was no correlation between IEL counts and villous to crypt ratio (Spearman rank correlation, -0.066; p = 0.80). CONCLUSIONS These results suggest that 25 IELs/100 epithelial cells (mean +2 SD) should be taken as the upper limit of the normal range for duodenal mucosa.
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Affiliation(s)
- M Hayat
- Centre for Digestive Diseases, General Infirmary at Leeds, Leeds LS1 3EX, UK.
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