Anti-tissue Transglutaminase Antibodies Research Articles

Reliability of anti-tissue transglutaminase antibodies in children with malnutrition

Objectives Serological markers are used in the diagnosis of celiac disease. Among these, the most widely used are tissue transglutaminase antibodies (anti-TG2 antibodies). It has been suggested that the mechanisms that are set in motion by malnutrition cause the tight connections between enterocytes to expand, which allows gluten-derived peptides to pass through the epithelium. This causes the production of anti-TG2 antibodies without the presence of celiac disease. Methods The patients who were examined for malnutrition and had their anti-TG2 antibody levels measured at the same time, were accepted into the study. The patients who were investigated for suspected celiac disease, showed no signs of malnutrition, and had their anti-TG2 antibody levels measured were accepted into a control group. Results The study population consisted of 126 children with mild malnutrition (54.8% female, 7.44 ± 5.38 years); 89 children with moderate malnutrition (54.8% female, 7.62 ± 5.43 years), and a control group of 200 children (53.2% female, 7.72 ± 5.05 years). According to the results, anti-TG2 IgG levels were significantly higher among patients in the mild and moderate malnutrition groups compared to patients in the control group (p = .02 and p = .01, respectively). However, there was no significant difference between the mild and moderate malnutrition groups (p > .05). Conclusions Malnutrition does not affect anti-TG2 IgA levels in children. However, anti-TG2 IgG levels increase in children suffering from malnutrition. When examining celiac disease, especially in people with a background IgA deficiency, doctors should consider whether malnutrition may be the cause of the increase in serum anti-TG2 IgG levels without celiac disease.

Prevalence of celiac disease in low and high risk population in Asia\u2013Pacific region: a systematic review and meta-analysis

This systematic review and meta-analysis study was conducted to estimate the pooled prevalence of CD in low and high risk groups in this region. Following keywords were searched in the Medline, PubMed, Scopus, Web of Science and Cochrane database according to the MeSH terms; celiac disease, prevalence, high risk population and Asian-Pacific region. Prevalence studies published from January 1991 to March 2018 were selected. Prevalence of CD with 95% confidence interval (CI) was calculated using STATA software, version 14. The pooled sero-prevalence of CD among low risk group in Asia–Pacific region was 1.2% (95% CI 0.8–1.7%) in 96,099 individuals based on positive anti-tissue transglutaminase (anti-t-TG Ab) and/or anti-endomysial antibodies (EMA). The pooled prevalence of biopsy proven CD in Asia–Pacific among high and low risk groups was 4.3% (95% CI 3.3–5.5%) and 0.61% (95% CI 0.4–0.8%) in 10,719 and 70,344 subjects, respectively. In addition, the pooled sero-prevalence and prevalence of CD in general population was significantly higher in children compared with adults and it was significantly greater in female vs. male (P < 0.05). Our results suggest high risk individuals of CD are key group that should be specifically targeted for prevention and control measures, and screening may prove to have an optimal cost–benefit ratio.

Hashimoto Tiroiditinin Çocuklarda ve Ergenlerde Geriye Dönük Analizi: Tek Merkez Deneyimi

Objective: Hashimoto’s thyroiditis is an organ-specific autoimmune disease and the most common cause of goiter and acquired hypothyroidism in children and adolescents in regions devoid of endemic iodine deficiency. In this study, it was aimed to examine the epidemiological, clinical and laboratory features of Hashimoto’s thyroiditis and autoimmune diseases accompanying Hashimoto’s thyroiditis in children and adolescents. Methods: We retrospectively examined thyrotropin, free thyroxin, thyroid autoantibodies (thyroid peroxidase and thyroglobulin antibodies), immunoglobulin A (IgA), anti-tissue transglutaminase antibodies (IgA-tTG), and thyroid ultrasonography findings of 108 cases aged 5-18 years with positive anti-thyroid antibodies. Results: The female/male ratio was 80/28 and 68% of the patients were adolescents. The most common admission complaint was goiter. At the time of diagnosis, the cases had euthyroidism (44.4%), subclinical hypothyroidism (35%), overt hypothyroidism (16.6%), and hyperthyroidism (3.7%). Goiter was detected in 58 (53.7%) cases by thyroid ultrasonography. During the follow-up, overt hypothyroidism developed in 6 patients who had subclinical hypothyroidism and subclinical hypothyroidism developed in 8 patients who had euthyroidism. All patients with hyperthyroidism became euthyroid. Levothyroxine treatment was administered to 47 (43.5%) patients. Celiac disease was detected in 2 and type 1 diabetes mellitus in 1 patient. Conclusions: The prevalence of Hashimoto’s thyroiditis increases with age both in childhood and adolescence, and thyroid functions tend to deteriorate over time. Therefore, close follow-up and appropriate treatment are important. Although the prevalence of celiac disease is higher in children and adolescents with Hashimoto’s thyroiditis compared to healthy children, the true prevalence of autoimmune diseases accompanying Hashimoto’s thyroiditis will be revealed in studies to be conducted in larger patient populations.

Celiac Disease in Children with Chronic Diarrhoea: A Cross-sectional Study

Introduction: Celiac disease is a chronic gastrointestinal disorder, very often underdiagnosed due to lack of awareness among the general practitioners. Aim: To study the prevalence of celiac disease among children with chronic diarrhoea. Materials and Methods: A cross-sectional study was conducted in which, 890 children between the age group of 1-18 years with history of chronic diarrhoea (loose stools or increased frequency for more than two weeks) were enrolled, between November 2015 and January 2018 in a tertiary care centre in India. The children were screened with serological tests for celiac disease and among those who were tested positive; the diagnosis was confirmed by intestinal biopsy. Results: Of the 890 patients with chronic diarrhoea, 252 (28.3%) were tested positive for anti-tissue Transglutaminase (tTG) antibodies with levels more than 10 times the upper normal limit. Among the 252 patients with positive serology, 144 patientshad intestinal biopsy findings suggestive of celiac disease (Marsh stage 3b and 3c) while the rest had normal or mild (marsh grade 1, 2 and 3a) histological changes. Conclusion: Celiac disease is one of the most important causes of chronic diarrhoea and hence should be actively looked for in children presenting with chronic diarrhoea.

Granular Deposits of IgA in the Skin of Coeliac Patients Without Dermatitis Herpetiformis: A Prospective Multicentric Analysis

Granular deposits of IgA represent the specific cutaneous marker of dermatitis herpetiformis. The prevalence of IgA deposits in the skin of patients with coeliac disease without dermatitis herpetiformis remains unknown. In this prospective case-control study, skin biopsies from newly diagnosed coeliac patients without dermatitis herpetiformis were analysed by direct immunofluorescence. Controls included healthy volunteers and patients with both bowel symptoms and skin eruptions unrelated to coeliac disease. Clinical data and serum level of anti-tissue transglutaminase and anti-epidermal transglutaminase IgA antibodies were collected from patients and controls. Granular deposits of IgA or IgA1 in the skin were found in 29 out of 45 patients with coeliac disease (64.4%), and in none of the included controls (specificity 100%; sensitivity 64.4%). Positive direct immunofluorescence correlated significantly with an increased serum level of anti-epidermal transglutaminase IgA antibodies (p < 0.005). This study shows that granular deposits of IgA represent a low sensitive, but highly specific, cutaneous marker of coeliac disease independent of dermatitis herpetiformis.

The profile of autoimmunity in Type 1 diabetes patients.

Background:Type 1 diabetes mellitus (T1DM) is an autoimmune disorder caused by pancreatic β-cells destruction. Anti-pancreatic antibodies are the witness of β-cell destruction and their dosage is mainly used for etiological diagnosis. Patients with T1DM are at increased risk of developing other autoimmune reactions, which may involve other organs, resulting in organ specific autoimmune disease. The most frequently encountered are autoimmune thyroid disease, followed by celiac and gastric disease and other rare autoimmune diseases.Objectives:The purpose of this study is to investigate the prevalence of autoimmune markers in patients with T1DM.Methods:The study was conducted at the Department of Endocrinology of the Military Hospital Moulay Ismail in Meknes Morocco, from January 2016 to December 2018. All Type 1 diabetes patients consulting during the study period were included in the study. Their clinical and biochemical data were collected at their first presentation, made up of anti-pancreatic antibodies (glutamic acid decarboxylase [GAD] antibody, tyrosine phosphatase antibody, and islet cell antibody) and other organ-specific antibodies: the thyroid (antithyroid peroxidase antibody, antithyroglobulin antibody, and antithyroid-stimulating hormone receptor antibody), the intestine (IgA antitissue transglutaminase antibody), the adrenal gland (anti-21 hydroxylase antibody), and the stomach (antigastric parietal cell antibody and anti-intrinsic factor antibody).Results:Fifty-four patients were included, with an average age of 26 years. GAD, tyrosine phosphatase, and islet cell antibodies were detected in 74%, 22%, and 3.7%, respectively, of the 54 patients examined. The prevalence of extrapancreatic autoimmunity was 45% with a large preponderance among different immunities of those from thyroid and celiac diseases (CDs).Conclusion:Our results confirm that patients with Type 1 diabetes should be investigated for the presence of autoimmune diseases mainly from thyroid and CDs.

Frontiers in Celiac Disease: Where Autoimmunity and Environment Meet.

Celiac disease is a chronic, immune-mediated enteropathy driven by dietary gluten found in genetically susceptible hosts. It has a worldwide distribution, is one of the most common autoimmune disorders globally, and is the only autoimmune condition for which the trigger is known. Despite advances in characterizing mechanisms of disease, gaps in understanding of celiac disease pathogenesis remain. A "frontier" concept is considering what moves an HLA-DQ2 or DQ8-positive individual from asymptomatic gluten tolerance to celiac disease manifestation. In this arena, environmental triggers, including age at the time of initial gluten exposure, the occurrence of usual childhood viral infections, and microbiome alterations have emerged as key events in triggering the symptomatic disease. Pathologists play a major role in frontier aspects of celiac disease. This includes the discovery that duodenal mucosal histology in follow-up biopsies does not correlate with ongoing patient symptoms, antitissue transglutaminase antibody titers and diet adherence in celiac disease patients. Further, in light of recent evidence that the detection of monoclonal T-cell populations in formalin-fixed biopsies is not specific for type II refractory celiac disease, pathologists should resist performing such analyses until common causes of "apparent" refractoriness are excluded. The promise of therapies in celiac disease has led to clinical trials targeting many steps in the inflammatory cascade, which depend upon a pathologist's confirmation of the initial diagnosis and evaluation of responses to therapies. As pathologists continue to be active participants in celiac disease research, partnering with other stakeholders, we will continue to impact this important autoimmune disease.

Seroprevalence of celiac disease among children in Baghdad, Iraq

Celiac disease (CD) represents A unique disorders in which consumption of a food ingredient namely gluten-containing grains (wheat, rye, barley) in combination with genetic susceptibility is fundamental for the development of an a guilefully evolving autoimmune reaction influence the gut and other organs. The present study determines the celiac disease among suspected children. From special the laboratory for Pathogenesis Analyses in Baghdad 100 blood children samples was collected during the period from 1st March 2018 till the 31 th of July 2018, analyzed by two serological test which were Anti-tissue transglutaminase (tGT) antibodies and Anti-gliadin antibodies for the presence of serum Immunoglobulin A (IgA tGT), Immunoglobulin G (IgG tGT), Immunoglobulin A (IgA AGA), Immunoglobulin G (IgG AGA) were measured by Enzyme-linked Immunosorbent Assay (ELISA). In result obtained positive serological test Trasglutaminase (tGT) for IgA tGT was 5 (16.7 %), IgG tGT was12 (40.0 %), more than Antiglidin Antibodies IgA AGA was 3 (10.0 %), IgG AGA was 10 (33.3 %). the males was 18 (32.1 %) more than female between (6 year - 9 year) age group which represent 10 (37.0 %). The symptoms of celiac disease found with weight loss 26 (86.7 %), chronic diarrhea 21 (70.0 %), vomiting 19 (63.3 %). In this study, obtained positive serological test Trasglutaminase for (IgA, IgG tGT) Antibodies in male between age group (6 year - 9 year) and with the symptoms more found with weight loss, chronic diarrhea, vomiting.

Small intestinal bacterial overgrowth among patients with celiac disease unresponsive to a gluten free diet.

Little is known about the relationship between small intestinal bacterial overgrowth (SIBO) and celiac disease (CeD) in patients who are unresponsive to a gluten-free diet (GFD). This study aimed to determine the SIBO prevalence in patients with CeD who are unresponsive to a GFD. We conducted a case-control study from July 2012 to September 2014. We included 32 patients with CeD who were unresponsive to a GFD and 52 healthy age- and sex-matched controls. Demographic, clinical, and laboratory data were obtained from patients' medical records. Antitissue transglutaminase antibody determined by enzyme-linked immunosorbent assay was recorded, and lactulose hydrogen breath test (LHBT) was used to detect SIBO in all participants. Microbiological analysis, including jejunal aspirates obtained using upper endoscopy, was performed for only 20 patients with CeD. A total of 10 (31%) of 32 patients with CeD and 4 (7.7%) of 52 controls tested positive for LHBT, with a statistically significant difference (p=0.007). Of 20 cultures, 3 (15%) were positive with no statistically significant correlation between the cultures and LHBT (p=0.05). In a subgroup analysis of children who were 18 years old or younger, 7/24 (29.2%) patients with CeD had a positive LHBT compared with 3/32 (9.4%) controls, but this difference was not statistically significant (p=0.08). The prevalence of SIBO was 31% in unresponsive patients with CeD according to LHBT and 15% in the quantitative culture of the jejunal aspirate, which is comparable with the published Western literature.

O2 Screening de autoanticuerpos anti-transglutaminasa tisular en pacientes pediátricos con diagnóstico reciente de diabetes mellitus, empleando un novedoso inmunoensayo

Introducción: la diabetes mellitus tipo 1 (DM1) y la enfermedad celíaca (EC) son enfermedades crónicas, poligénicas y multifactoriales vinculadas con una disfunción del sistema inmune. Se presentan en simultaneidad en un 10% de los pacientes, por lo cual se recomienda el screening de rutina para EC en pacientes con reciente diagnóstico de DM1.Objetivos: realizar un screening en pacientes pediátricos con diagnóstico de DM1 para evaluar la presencia de autoanticuerpos anti-transglutaminasa tisular (tTgA), utilizando un método basado en citometría de flujo (FloCMIA: Flow Cytometric Microsphere based Immunoassay).Materiales y métodos: se ensayaron sueros de 253 pacientes pediátricos con diagnóstico reciente de DM1 y se evaluó la presencia de tTgA mediante FloCMIA. Se empleó un modelo de doble paratope incubando los sueros con microesferas de poliestireno de 5 µm adsorbidas con la transglutaminasa tisular recombinante (His6tTg), ON a 4 ºC. La mezcla se incubó con His6tTg marcada con biotina y los inmunocomplejos formados se detectaron empleando estreptavidina-ficoeritrina y se adquirió en un citómetro de flujo. Los resultados fueron expresados en Standard Deviation scores (SDs), considerando positivas las muestras con SDs&gt;1,7. Las muestras tTgA positivas por FloCMIA se contrastaron con un kit de ELISA comercial.

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

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. 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. 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. 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. 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.

S1302 Follow-Up Outcomes in Celiac Disease Patients Followed at a Large, Community-Based Gastroenterology Practice

INTRODUCTION: Celiac disease (CD) is a chronic illness caused by an immune response to gluten and diagnosed with anti-tissue transglutaminase antibody testing and duodenal biopsies. Treatment is adherence to a gluten-free diet (GFD) which requires effective patient education, motivation, and frequent follow-up visits. Guidelines from prior studies in large academic settings recommend dietician referrals at time of diagnosis and periodic testing for micronutrient deficiencies. However, there is limited data to guide practice parameters in a community-based practice. The purpose of this study was to evaluate guideline adherence by community-based gastroenterologists. METHODS: We assessed CD care based on follow-up rates, micronutrient testing, symptoms and serology results in cohorts with and without dietician referrals. This retrospective study analyzed patients at Rockford Gastroenterology Associates (RGA), in Rockford, IL: a large private practice of 14 gastroenterologists and 7 nurse practitioners. Patients were included if they had a diagnosis from January 1, 2014 through December 31, 2018, based on positive serology and/or biopsy. Patient data was collected by chart review and analyzed through Microsoft Excel and SPSS. RESULTS: A cohort of 126 patients (84 female) met inclusion criteria. 69.8% had a dietician referral order. 65.9% had at least one lab test order for any of the 6 micronutrients (Table 1). Of the 80.2% that attended at least one follow-up appointment, 34.9% had only one and 19.8% had only two (Figure 1). A smaller cohort (79 patients), excluding those without follow-up symptom or serology data, was used for separating patients into 4 categories (Figure 2). Although patients with a referral had a higher proportion (32% vs 26%) in the asymptomatic and negative serology category, this was not statistically significant based on a fisher exact test value of 2.62 (P = .466). CONCLUSION: Dietician referral, micronutrient testing, and close follow-up are important parameters that affect outcomes in CD patients. The rates for dietician referral, some micronutrient testing and follow-up visits were higher than 50% in this study. Although a greater percentage of patients with a dietician referral were asymptomatic and had negative serology, this was not statistically significant. A larger, long-term study is needed to assess clinical outcomes in these patients and modify guidelines for the feasibility and practicality of multiple lab testing and follow-up care in community-based practice.Table 1.: Micronutrient orders and testing rates at follow-upFigure 1.: Time interval between time of diagnosis and follow-up visits.Figure 2.: Categorization of patients by symptoms and serology results.

Prevalence of celiac disease in patients with short stature: A systematic review and meta-analysis.

Short stature is a common extraintestinal manifestation of celiac disease (CeD). We conducted a systematic review and meta-analysis to assess the global prevalence of CeD in patients presenting with short stature. We searched Medline and EMBASE databases for the keywords "celiac disease, coeliac disease, anti-gliadin, tissue transglutaminase antibody, anti-endomysial antibody, short stature and growth retardation." All the studies published from January 1991 to May 2020 were included. Patients without any prior evaluation for short stature were classified as all-cause short stature, while prior evaluated patients, where no cause was found for short stature, were classified as idiopathic short stature. The diagnosis of CeD was based on the European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines. A random-effects model was used to pool the data. Seventeen studies screening 3759 patients (1582 with all-cause short stature and 2177 with idiopathic short stature) were included. The pooled seroprevalence of CeD based on positive anti-tissue transglutaminase antibody and anti-endomysial antibody was 11.2% (95% CI 4.0-21.2%; I2 =86%) and 9.7% (95% CI 2.7-20.2%; I2 =95%) for all-cause and idiopathic short stature, respectively. Similarly, pooled prevalence of biopsy-confirmed CeD was 7.4% (95% CI 4.7-10.6%; I2 =76%) and 11.6% (95% CI 4.1-22.2%; I2 =97%), for all-cause and idiopathic short stature, respectively. There was an overall severe risk of selection bias and significant heterogeneity in the pooled results. Approximately one in 14 patients with all-cause short stature and one in nine patients with idiopathic short stature had biopsy-confirmed CeD. Therefore, evaluation for CeD may be prudent in all patients with short stature.

Celiac Dietary Adherence Test and Standardized Dietician Evaluation in Assessment of Adherence to a Gluten-Free Diet in Patients with Celiac Disease

Adherence to a gluten-free diet (GFD) is currently the mainstay of treatment strategy for celiac disease (CD). The aim of our study was measuring a GFD adherence in CD patients using two newly validated methods of dietary assessment—Standardized Dietician Evaluation (SDE) and the Celiac Dietary Adherence Test (CDAT). Ninety-two adults with CD were evaluated by a registered dietitian with extensive experience with the use of SDE and CDAT. Duodenal biopsy was performed and blood was drawn for serum anti-endomysial, anti-deamidated gliadin peptide and anti-tissue transglutaminase antibodies in forty four of those patients. The results of CDAT and SDE were very convergent, but SDE scores better correlated with serologic and histologic findings. As many as 24–52% of study participants did not adhere well enough to a GFD. Insufficient adherence to a GFD in CD patients is still a significant problem. The knowledge about gluten content in food ingredients and additives is very low among adults with CD. SDE is the most accurate method in assessing compliance with a GFD and is especially helpful in determining hidden sources of gluten. The CDAT may be a fast tool for screening for a GFD adherence in CD patients.

The Value of Screening for Celiac Disease in Systemic Lupus Erythematosus: A Single Experience of a Tertiary Medical Center.

IntroductionSystemic lupus erythematosus (SLE) is a multi-organ inflammatory disease associated with autoimmune diseases. The aim of the study is to assessed the frequency of celiac disease (CD) in adults and children with SLE (aSLE and cSLE, respectively) and compare them with rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) patients; the study also explored the clinical impact of CD serologic markers on SLE disease activity and severity.MethodsThis was a cross-sectional study. Patients with SLE who had regular follow-up in rheumatology clinics were evaluated for laboratory and clinical variables using serology and the SLE Disease Activity Index (SLEDAI). To assess the occurrence of CD serology in cSLE and aSLE and the clinical impact of CD serologic markers on SLE, patients were tested for antigliadin (AGA), anti-endomysium (EmA) and anti-tissue transglutaminase (tTG) antibodies. RA and JIA patients were included for comparison. Duodenal biopsy was conducted in patients who exhibited CD markers.ResultsThe CD marker was found in 29 (11.6%) of the 250 patients. AGA was present in seven aSLE patients and tTG in two (11.1%). Among cSLE patients, the autoantibody was present in 17.6% (AGA in four, tTG in two, and EmA in three). For RA patients, five had AGA and tTG and one had EmA, with an overall positivity of 9.7%. Five JIA patients had AGA (four with EmA and five with tTG) with overall positivity of 10.9%; the serum IgA level was normal in all patients except one. Duodenal endoscopic biopsy was performed in patients with positive CD markers (two declined). Histologic confirmation of CD was reported in one RA and one JIA patient but in none of the SLE patients. There was no correlation between the presence of CD markers and autoantibodies in SLE.ConclusionCD antibodies did not influence SLE activity. Thus, SLE patients may not need to be screened for CD antibodies.

Non-invasive prediction of persistent villous atrophy in celiac disease.

BACKGROUNDCeliac disease (CD) is an immune-mediated enteropathy that is primarily treated with a gluten-free diet (GFD). Mucosal healing is the main target of the therapy. Currently, duodenal biopsy is the only way to evaluate mucosal healing, and non-invasive markers are challenging. Persistent elevation of anti-tissue transglutaminase antibodies (aTTG) is not an ideal predictor of persistent villous atrophy (VA). Data regarding prediction of atrophy using anti-deamidated gliadin peptide antibodies (aDGP) and abdominal ultrasonography are lacking.AIMTo evaluate the ability of aTTG, aDGP, small bowel ultrasonography, and clinical and laboratory parameters in predicting persistent VA determined using histology.METHODSPatients with CD at least 1 year on a GFD and available follow-up duodenal biopsy, levels of aTTG and aDGP, and underwent small bowel ultrasonography were included in this retrospective cohort study. We evaluated the sensitivity, specificity, and positive and negative predictive values of aTTG, aDGP, small bowel ultrasonography, laboratory and clinical parameters to predict persistent VA. A receiver operating characteristic (ROC) curve analysis of antibody levels was used to calculate cut off values with the highest accuracy for atrophy prediction.RESULTSComplete data were available for 82 patients who were followed up over a period of four years (2014-2018). Among patients included in the analysis, women (67, 81.7%) were predominant and the mean age at diagnosis was 33.8 years. Follow-up biopsy revealed persistent VA in 19 patients (23.2%). The sensitivity and specificity of aTTG using the manufacturer’s diagnostic cutoff value to predict atrophy was 50% and 85.7%, respectively, while the sensitivity and specificity of aDGP (using the diagnostic cutoff value) was 77.8% and 75%, respectively. Calculation of an optimal cutoff value using ROC analysis (13.4 U/mL for aTTG IgA and 22.6 U/mL for aDGP IgA) increased the accuracy and reached 72.2% [95% confidence interval (CI): 46.5-90.3] sensitivity and 90% (95%CI: 79.5-96.2) specificity for aDGP IgA and 66.7% (95%CI: 41.0-86.7) sensitivity and 93.7% (95%CI: 84.5-98.2) specificity for aTTG IgA. The sensitivity and specificity of small bowel ultrasonography was 64.7% and 73.5%, respectively. A combination of serology with ultrasound imaging to predict persistent atrophy increased the positive predictive value and specificity to 88.9% and 98% for aTTG IgA and to 90.0% and 97.8% for aDGP IgA. Laboratory and clinical parameters had poor predictive values.CONCLUSIONThe sensitivity, specificity, and negative predictive value of aTTG and aDGP for predicting persistent VA improved by calculating the best cutoff values. The combination of serology and experienced bowel ultrasound examination may achieve better accuracy for the detection of atrophy.

Adherence to Gluten-free Diet in a Celiac Pediatric Population Referred to the General Pediatrician After Remission.

Assessment of adherence to gluten-free diet in celiac disease (CD) is generally recommended. Few data are available about consequences of transition from the referral center to the general pediatrician (GP) once remission is achieved. Adherence was assessed in patients referred to the GP for an annual basis follow-up, called back for re-evaluation. Immunoglobulin A (IgA) antitissue transglutaminase (anti-tTG) antibodies and the Biagi score (BS) were determined at last follow-up at the referral center (V1), and at re-evaluation (V2). Patients were classified as adherent (BS 3-4, IgA anti-tTG <7 U/mL) and nonadherent (BS 0-2, IgA anti-tTG ≥7). Scores of adherence were correlated with personal and clinical data. We evaluated 200 patients. Overall, we found good adherence rates in 94.95% of patients at V1 and 83.5% at V2. IgA anti-tTG were negative in 100% at V1 and 96.97% at V2. BS is 3 to 4 in 94.5% at V1 and 84% at V2. Adherence at V2 was significantly worse than V1 (P < 0.001). No significant associations were found between scores of adherence and sex, symptoms and age at diagnosis, family history of CD, comorbidity, and diagnosis by endoscopy. Age 13 years or older represents a risk factor for lack of compliance at V1 (P = 0.02) and V2 (P = 0.04), and foreign nationality at V2 (P = 0.001). The BS, serology, and a clinical interview, integrated, are reliable tools for assessing pediatric adherence to gluten-free diet. We argue that referring patients to the GP after remission of CD is important, but the process must be improved and recommendations are required.

Endoscopic Diagnosis Of Mixed Parasitic Infestation As An Uncommon Cause Of Iron Deficiency Anaemia

Iron deficiency anaemia (IDA) is confirmed by a low level of haemoglobin (Hb), low ferritin or iron level in addition to hypochromic microcytic blood picture. It is ideal to get a coeliac screen with either anti-tissue transglutaminase (Anti-tTG) or anti-endomysial antibodies along with serum immunoglobulin IgA.

Immunosuppression-induced clonal T-cell lymphoproliferative disease causing severe diarrhoea mimicking coeliac disease following renal transplantation: a case report

BackgroundPost-transplant lymphoproliferative disease is a recognized complication following solid organ transplantation. This is usually a B cell disease and frequently associated with Epstein Barr virus infection, although T cell PTLD can occur. T cell PTLD is usually a monomorphic, lymphomatous disease associated with an adverse prognosis.Case reportWe report a 52 year old male pre-emptive renal transplant recipient who developed severe diarrhea with weight loss following intensification of his immunosuppression due to antibody mediated rejection 3 years after transplantation. Duodenal biopsy demonstrated monoclonal CD8+ T cell duodenitis leading to increased intraepithlieal lymphocytes and sub-total villous atrophy mimicking coeliac disease. Coeliac disease was excluded by negative anti-tissue transglutaminase antibody, HLA-DQ2 and HLA-DQ8 testing. There was no evidence of lymphoma either on biopsy or CT enterography and no FDG avid disease on PET. Symptoms did not improve with reduction of immunosuppression, but resolved fully on complete withdrawal of treatment. The transplant failed and he was established on dialysis. The diagnosis was early PTLD.ConclusionsOesophagogastroduodenoscopy with small bowel biopsies is a useful investigation for determining the cause of diarrhoea in renal transplant patients when more common causes have been excluded. This is the first report that we are aware of clonal T cell PTLD mimicking coeliac disease which only resolved after complete withdrawal of immunosuppression. As treatments for lymphoma are aggressive they are only initiated in the malignant phase and management of early stage PTLD is to minimise risk of progression by reducing immunosuppression. Any plans to retransplant will have to take into consideration the possibility that PTLD will recur.

Change in Patient MELD-Na and Albumin Level From the Time of Celiac Disease Diagnosis to Six Months Later After Gluten-Free Diet.

Background & aimsCeliac disease (CD) is a multisystem disorder triggered by dietary gluten in genetically predisposed individuals that may affect any organ system, including the liver. We evaluated a change in patient model for end-stage liver disease (MELD)-Na and albumin level from the time of celiac disease diagnosis to six months later, after implementing a gluten-free diet.MethodsA retrospective study was conducted from January 1, 2006, to June 30, 2018. CD was diagnosed based on celiac antibodies and/or histopathological data. MELD-Na and albumin were calculated at the start of the gluten-free diet and six months later. Additional variables like gender, ethnicity, serum IgA level, serum IgG level, human leukocyte antigen (HLA) type, and markers of end-stage liver disease were collected. Descriptive statistics, including means, were reported with the standard deviation for the continuous variables along with frequencies and percentages for all categorical variables.ResultsA total of 18 patients (55.6% male) were identified as having both cirrhosis and CD. The mean age at the time of celiac diagnosis was 53.6, and 94.4% were Caucasian. CD was diagnosed using celiac antibodies (100%) and histopathological data (44.4%). Most common celiac antibodies include anti-tissue transglutaminase antibodies (77.8%). End-stage liver disease markers like abdominal ascites (55.6%), variceal bleed (50.0%), acute or chronic kidney injury (16.7%), hepatocellular carcinoma (HCC) (11.1%), hepatic encephalopathy (HE) (50.0%), spontaneous bacterial peritonitis (SBP) (5.6%), and liver transplant (0.0%) were seen. The mean baseline MELD-Na score was 11.8, and albumin was 3.5 at the time of celiac diagnosis and mean MELD-Na was 11.8, and albumin was 3.5 six months after a gluten-free diet.ConclusionIt is difficult to conclude any exact relationship between change in MELD-Na score after gluten-free diet, but an improving trend is noted in patients with higher MELD-Na score such as 17 or higher. There is no change or worsening of MELD-Na score in patients with lower MELD-Na score. There was no change in mean MELD-Na and albumin level after gluten-free diet.