Presence of alarm symptoms at coeliac disease diagnosis is not associated with poorer long-term treatment outcomes.

Celiac Disease: The Endocrine Connection

What Is the Role of Serologic Testing in Celiac Disease? A Prospective, Biopsy-Confirmed Study With Economic Analysis

The role of capsule endoscopy in patients with nonresponsive celiac disease

BACKGROUND AND OBJECTIVES:Celiac disease (CD) is an immune-mediated enteropathy, induced by gluten in genetically susceptible individuals. The objective of this study was to describe the clinical pattern of CD in children from the western region of Saudi Arabia.DESIGN AND SETTING:Retrospective, hospital-based.PATIENTS AND METHODS:This study included children with a biopsy-proven diagnosis of CD made between September 2002 and July 2007. Children were admitted to the endoscopy unit for a small-bowel biopsy if they had gastrointestinal symptoms suggestive of CD or if they were positive for a CD-antibody screen performed for the high-risk groups.RESULTS:Eighty children were identified with a diagnosis of CD. Their mean (SD) age was 9.6 (4.9) years (range, 0.5-18 years). There were 44 (55%) female patients. Forty-one (51%) patients were detected during screening of high-risk groups, while 39 (49%) patients had classical symptoms of malabsorption. The screening also detected asymptomatic patients. Of 65 patients tested, 11 (17%) had elevated liver function tests, which reverted to normal after introduction of a gluten-free diet (GFD) except in one case. Seventy-three (91%) patients were positive for anti-tissue transglutaminase antibodies, 18 (23%), for IgG anti-gliadin antibodies; and 46 (58%), for IgA anti-gliadin antibodies. Forty-one (56%) patients showed good adherence to GFD as assessed by dietary history and the decline in anti-tTG level.CONCLUSION:CD may present with classical symptoms or be identified through screening programs. Growth and laboratory abnormalities usually improve after introduction of a GFD. Adherence to a GFD remains a problem; therefore, thorough assessment and counseling at the time of diagnosis and ongoing care are crucial.

Celiac Disease Beyond the Gut

Association of celiac disease and intestinal lymphomas and other cancers

<h3>Introduction</h3> The majority of coeliacs have few obvious gastrointestinal (GI) symptoms despite the presence of the enteropathy, have atypical symptoms or have physiological derangements such as iron deficiency anaemia or osteoporosis. It is not clear whether these coeliacs have a reduced quality of life or whether quality of life changes following treatment with withdrawal of gluten from the diet. Johnson <i>et al.</i> (n = 14) observed silent coeliacs had no different life quality at diagnosis nor following 1 year of treatment in comparison to healthy controls1 though Nachman <i>et al.</i> (n = 8) observed silent coeliacs had significantly worse off quality of life in comparison to controls at diagnosis.2 Our aim was to describe the quality of life at diagnosis of coeliac disease in a large contemporary cohort and observe any change following treatment with a gluten-free diet (GFD). <h3>Methods</h3> 151 adults newly diagnosed with coeliac disease between 2007 and 2008 at Nottingham, Sheffield and Derby were studied. Quality of life was assessed with SF36 questionnaire. Paired t tests were used to examine changes in SF36 quality of life scores from diagnosis of coeliac disease and following 12 months treatment with GFD. Incident coeliacs were categorised as having a classic presentation (presenting with weight loss and diarrhoea, n = 22); presenting with GI symptoms (n = 85); or having occult disease (no GI symptoms or have physiological derangements such as anaemia in absence of GI symptoms, n = 44). <h3>Results</h3> Mean SF36 score at diagnosis of coeliac disease was highest in those presenting with occult disease (65.1 (SD 18.6)) and lowest in those with classic disease (48.7 (SD 19.3)). Following exposure to 12 months GFD, there was a statistically significant improvement in quality of life (table 1). The improvement in SF36 score with a GFD was similar regardless of their presenting symptoms at diagnosis. <h3>Conclusion</h3> Following diagnosis and treatment of coeliac disease with a GFD, we observed an improvement in quality of life that was similar regardless of the presenting symptoms and signs recorded at diagnosis and the baseline quality of life. Without a randomised controlled trial, we cannot be sure of the true magnitude of this effect over placebo.

Introduction The majority of coeliacs have few obvious gastrointestinal (GI) symptoms despite the presence of the enteropathy, have atypical symptoms or have physiological derangements such as iron deficiency anaemia or osteoporosis. It is not clear whether these coeliacs have a reduced quality of life or whether quality of life changes following treatment with withdrawal of gluten from the diet. Johnson et al. (n = 14) observed silent coeliacs had no different life quality at diagnosis nor following 1 year of treatment in comparison to healthy controls1 though Nachman et al. (n = 8) observed silent coeliacs had significantly worse off quality of life in comparison to controls at diagnosis.2 Our aim was to describe the quality of life at diagnosis of coeliac disease in a large contemporary cohort and observe any change following treatment with a gluten-free diet (GFD). Methods 151 adults newly diagnosed with coeliac disease between 2007 and 2008 at Nottingham, Sheffield and Derby were studied. Quality of life was assessed with SF36 questionnaire. Paired t tests were used to examine changes in SF36 quality of life scores from diagnosis of coeliac disease and following 12 months treatment with GFD. Incident coeliacs were categorised as having a classic presentation (presenting with weight loss and diarrhoea, n = 22); presenting with GI symptoms (n = 85); or having occult disease (no GI symptoms or have physiological derangements such as anaemia in absence of GI symptoms, n = 44). Results Mean SF36 score at diagnosis of coeliac disease was highest in those presenting with occult disease (65.1 (SD 18.6)) and lowest in those with classic disease (48.7 (SD 19.3)). Following exposure to 12 months GFD, there was a statistically significant improvement in quality of life (table 1). The improvement in SF36 score with a GFD was similar regardless of their presenting symptoms at diagnosis. Conclusion Following diagnosis and treatment of coeliac disease with a GFD, we observed an improvement in quality of life that was similar regardless of the presenting symptoms and signs recorded at diagnosis and the baseline quality of life. Without a randomised controlled trial, we cannot be sure of the true magnitude of this effect over placebo.

Gluten-Free Diets in Celiac Disease: Does Life Mean Life?

Follow-up of patients with celiac disease: Achieving compliance with treatment

Celiac disease: India on the global map

To the Editor: Celiac disease (CD) is a permanent autoimmune disorder triggered by the ingestion of gluten of wheat, rye and barley that can be recognized at any age. Manifestations of CD in older adults can be hidden, and a correct diagnosis is often not made.1 People with CD have a high risk of developing autoimmune disorders and cancer, and these findings are associated with age of diagnosis, especially gastrointestinal malignancies.2 This study presents Brazilians diagnosed with CD at the age of 60 and older, showing the clinical pattern; laboratory, endoscopic, and histological findings; follow-up; and cause of death. Fourteen patients were studied (7 men, mean age 68.1; 7 women, mean age 65.6). The diagnosis of CD was based on serological antiendomysium or antitransglutaminase antibodies and endoscopic and histological findings (Table 1). The follow-up consisted of interviews, clinical examination, and laboratory tests. Adherence to a gluten-free diet (GFD) was measured using interviews and questionnaires. All the participants were of European descent. Table 1 shows the demographic, clinical, and diagnostic characteristics of the study participants. Participants presented with the classic features of CD, such as diarrhea (100%), abdominal distention (92.8%), weight loss (92.8%), bloating (85.7%), weakness (78.6%), abdominal pain (50%), and steatorrhea (28.6%). Anemia was detected in 81.8% of participants and hypoalbuminemia in 72.7%. Low bone mineral density (BMD) indicated femur and spinal cord osteoporosis in 85.7%. Bone fractures occurred in two women. Two women presented with Hashimoto's thyroiditis and one man with adrenal insufficiency. Depression was diagnosed in seven. Other disorders observed were diverticular disease of the colon (n=2) and prostatic hypertrophy (n=3). Two patients died from myocardial infarction (1 man, 1 woman) 3 and 4 years, respectively, after the diagnosis of CD. Despite the presence of classic clinical features, delay in the diagnosis of CD ranged from 2 months to 36 years (Table 1). Three women had another relative with CD (1 sister, 1 daughter, and 1 son and 1 granddaughter in the same family) screened according to serological tests. In all of them, CD was confirmed using biopsy. Adherence to a GFD was 100%, with complete disappearance of symptoms and better quality of life. No symptoms or signs related to CD complications have been observed. The number of individuals aged 60 and older diagnosed with CD is progressively increasing worldwide.3 In the present study, the proportion and mean age of the men and women were similar. The delay in diagnosis was also observed in other countries. The European origin of the patients reflects the admixture in the colonization of southern Brazil. In this geographic area, the prevalence of CD was estimated to be 1 in 475.4 Relatives of people with CD have a greater risk of developing CD,5 as demonstrated in this study. Pancreatic insufficiency is found in older adults before the diagnosis of CD is confirmed,6 associated with steatorrhea as observed in the current study (28.6%). Moreover, small intestine bacterial overgrowth (14.3%) may have contributed to malabsorption of nutrients,7 corroborated by the findings of anemia and hypoalbuminemia in the current study. Several authors have found a higher risk of cancer in older adults with CD; this finding was associated with age and the duration of gluten exposure. No malignant disorder was diagnosed in the participants in the current study, and no neurological involvement was detected. The endoscopic findings suggesting CD were observed in 66.6% of the participants, as other authors have described (Table 1).8 There are few case reports linking CD to peptic disease. In the present study, peptic ulcers were detected in 21.4% of the patients, all were positive for Helicobacter pylori.9 Two patients died from myocardial infarction after CD treatment; the effect of a GFD on cardiovascular risk factors needs to be better understood.10 In conclusion, CD is present in older Brazilians, in whom diagnosis is often delayed, leading to repercussions in their nutritional state. Tumors are generally presumed to cause weight loss and weakness in older adults, leading to some being investigated using invasive methods, without physicians considering the possibility of CD. Because a GFD improves well-being, physicians must be alert to the diagnosis of CD in patients aged 60 and older. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Lorete Kotze: Concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparation of manuscript. Renato M. Nisihara: Concept and design, acquisition of subjects and data, serological tests, analysis and interpretation of data, and preparation of manuscript. Luiz R. Kotze: Acquisition of subjects and data, specimen analysis, and interpretation of data. Shirley R. R. Utiyama: Concept and design, analysis and interpretation of data, and preparation of manuscript. Sponsor's Role: No sponsor.

Celiac disease: how many biopsies for diagnosis?

Clinical presentation of celiac disease in the pediatric population

To assess the influence of gluten-free diet (GFD) compliance on the quality of life (QOL) of adolescents with coeliac disease (CD), and the impact of patient's age at time of diagnosis. Participants included 365 subjects: 283 adolescents (10-20 years old) with biopsy-proven CD and 82 adolescents without a chronic condition matched for age, sex, education, and social status. Their subjective QOL-comprising physical, mental, and social dimensions as defined by the World Health Organization-was measured and has been analyzed according to compliance status and age at CD diagnosis. Adolescents noncompliant with GFD reported a lower general QOL, more physical problems, a higher burden of illness, more family problems, and more problems in leisure time than adolescents who are compliant with GFD. More frequent GFD transgressions were associated with poorer QOL. Higher problem anticipation and higher feelings of "ill-being" were found in the noncompliant group. No differences between compliant patients with CD and adolescents without any chronic condition were found in all QOL aspects. Adolescents with a late CD diagnosis showed more problems at school and in social contact with peers, as well as worse physical health and higher CD-associated burden. Compliance with GFD is an essential factor to obtain optimal QOL. Psychosocial and educational support should be provided for patients having difficulties strictly adhering to GFD. Early CD onset and diagnosis is associated with better physical health, lower CD-associated burden and fewer social problems, indicating the importance of the earliest CD diagnosis possible.