Endoscopic Duodenal Biopsy Research Articles

Enteral delivery of proteins enhances the expression of proteins involved in the cytoskeleton and protein biosynthesis in human duodenal mucosa

ABSTRACT Background: Amino acids are well known to be key effectors of gut protein turnover. We recently reported that enteral delivery of proteins markedly stimulated global duodenal protein synthesis in carbohydrate-fed healthy humans, but specifically affected proteins remain unknown. Objective: We aimed to assess the influence of an enteral protein supply on the duodenal mucosal proteome in carbohydrate-fed humans. Design: Six healthy volunteers received for 5 h, on 2 occasions and in random order, either an enteral infusion of maltodextrins alone (0.25 g · kg−1 · h−1) mimicking the fed state or maltodextrins with a protein powder (0.14 g proteins · kg−1 · h−1). Endoscopic duodenal biopsy specimens were then collected and frozen until analysis. A 2-dimensional polyacrylamide gel electrophoresis–based comparative proteomics analysis was then performed, and differentially expressed proteins (at least ±1.5-fold change; Student’s t test, P < 0.05) were identified by mass spectrometry. Protein expression changes were confirmed by Western blot analysis. Results: Thirty-two protein spots were differentially expressed after protein delivery compared with maltodextrins alone: 28 and 4 spots were up- or downregulated, respectively. Among the 22 identified proteins, 11 upregulated proteins were involved either in the cytoskeleton (ezrin, moesin, plastin 1, lamin B1, vimentin, and β-actin) or in protein biosynthesis (glutamyl-prolyl–transfer RNA synthetase, glutaminyl–transfer RNA synthetase, elongation factor 2, elongation factor 1δ, and eukaryotic translation and initiation factor 3 subunit f). Conclusions: Enteral delivery of proteins altered the duodenal mucosal proteome and mainly stimulated the expression of proteins involved in cytoskeleton and protein biosynthesis. These results suggest that protein supply may affect intestinal morphology by stimulating actin cytoskeleton remodeling. This trial was registered at clinicaltrials.gov as NCT01254110.

Prevalence of celiac disease in adult patients with iron-deficiency anemia of obscure origin in Kashmir (India).

The purpose of this study was to evaluate the prevalence of celiac disease in adult patients with iron-deficiency anemia of obscure origin. One hundred and sixty-one consecutive patients with iron-deficiency anemia of obscure origin were evaluated. Tissue transglutaminase antibodies levels were done and duodenal biopsies were scored according to Marsh classification. Diagnosis was based on positiveIgA anti-tissue transglutaminase antibodies and abnormal histopathology. Gluten-free diet (GFD) was adviced for celiac disease patients. One hundred and sixty healthy blood donors were tested for IgA anti-tissue transglutaminase antibodies, and positive controls were subjected to endoscopic duodenal biopsy. Tissue transglutaminase antibodies were positive in 13 (8%) patients with iron-deficiency anemia of obscure origin and 4 (2.5%) in control group (p = 0.026) (odds ratio 3.42; 95% confidence interval [CI]: 1.092-10.743). All 13 patients (8%) and 2 out of 4 positive controls (1.25%) had histopathology findings of celiac disease (p = 0.004). Duodenal biopsy showed Marsh grade 1 in 4, grade 2 in 4 (30.77%), 3a in 1 (7.70%), 3b in 2 (15.38%), and 3c in 2 (15.38%) patients. A statistically significant correlation was found between lower hemoglobin concentration and higher Marsh grading (Spearman's rho = -0.946, p = 0.001). Celiac disease patients adhered to GFD and after 6months mean (SD) hemoglobin levels increased from 7.42 ± 0.96 to 10.47 ± 0.80g/dL (p- < 0.001). Patients with iron-deficiency anemia of obscure origin had increased prevalence of celiac disease. Gluten-free diet improved anemia in celiac disease patients irrespective of grade of duodenal involvement.

Celiac Disease: A Disease With Varied Manifestations in Adults in India

BackgroundIn India incidence of celiac disease is rising and more prevalent in the Northern part of the country, the so-called “coeliac belt”, a finding that is at least partially explained by the wheat-rice shift from the North to the South.Aim and MethodsThe aim of the present study was to determine clinical manifestations of celiac disease in western India. In retrospective analysis of prospectively maintained data at single tertiary health center, Patients diagnosed with CD based on modified ESPGHAN criteria were evaluated for clinical features, serology and histology of endoscopic duodenal biopsy.ResultA total of 75 patients diagnosed by modified ESPGHAN criteria (46 females, mean age 36±15 years) had positive serology- IgA Anti Endomyceal antibody (n-72), IgA Anti tTG antibody (n-3) and 6%, 28%, 3%, 62% patients had Marsh stage 0, 1, 2,and 3 respectively. Sixty-five percent of patients presented with typical diarrheal disease. One or more associated diseases were noted in 27 (36%) patients and most common being autoimmune disease (16%) (Hypothyroidism, grave’s disease, autoimmune hepatitis, DM type 1, Rheumatoid arthritis) followed by neurological conditions (9%) (Epilepsy, depression, schizophrenia, ataxia, migraine). Most common atypical manifestations were anaemia (76%) followed by elevated transaminases (39%), osteopenia (25%), neurological (4%) and infertility (1%).ConclusionCeliac disease is also common in western India and atypical manifestations and associated conditions should be actively screened in all CD patients. BackgroundIn India incidence of celiac disease is rising and more prevalent in the Northern part of the country, the so-called “coeliac belt”, a finding that is at least partially explained by the wheat-rice shift from the North to the South. In India incidence of celiac disease is rising and more prevalent in the Northern part of the country, the so-called “coeliac belt”, a finding that is at least partially explained by the wheat-rice shift from the North to the South. Aim and MethodsThe aim of the present study was to determine clinical manifestations of celiac disease in western India. In retrospective analysis of prospectively maintained data at single tertiary health center, Patients diagnosed with CD based on modified ESPGHAN criteria were evaluated for clinical features, serology and histology of endoscopic duodenal biopsy. The aim of the present study was to determine clinical manifestations of celiac disease in western India. In retrospective analysis of prospectively maintained data at single tertiary health center, Patients diagnosed with CD based on modified ESPGHAN criteria were evaluated for clinical features, serology and histology of endoscopic duodenal biopsy. ResultA total of 75 patients diagnosed by modified ESPGHAN criteria (46 females, mean age 36±15 years) had positive serology- IgA Anti Endomyceal antibody (n-72), IgA Anti tTG antibody (n-3) and 6%, 28%, 3%, 62% patients had Marsh stage 0, 1, 2,and 3 respectively. Sixty-five percent of patients presented with typical diarrheal disease. One or more associated diseases were noted in 27 (36%) patients and most common being autoimmune disease (16%) (Hypothyroidism, grave’s disease, autoimmune hepatitis, DM type 1, Rheumatoid arthritis) followed by neurological conditions (9%) (Epilepsy, depression, schizophrenia, ataxia, migraine). Most common atypical manifestations were anaemia (76%) followed by elevated transaminases (39%), osteopenia (25%), neurological (4%) and infertility (1%). A total of 75 patients diagnosed by modified ESPGHAN criteria (46 females, mean age 36±15 years) had positive serology- IgA Anti Endomyceal antibody (n-72), IgA Anti tTG antibody (n-3) and 6%, 28%, 3%, 62% patients had Marsh stage 0, 1, 2,and 3 respectively. Sixty-five percent of patients presented with typical diarrheal disease. One or more associated diseases were noted in 27 (36%) patients and most common being autoimmune disease (16%) (Hypothyroidism, grave’s disease, autoimmune hepatitis, DM type 1, Rheumatoid arthritis) followed by neurological conditions (9%) (Epilepsy, depression, schizophrenia, ataxia, migraine). Most common atypical manifestations were anaemia (76%) followed by elevated transaminases (39%), osteopenia (25%), neurological (4%) and infertility (1%). ConclusionCeliac disease is also common in western India and atypical manifestations and associated conditions should be actively screened in all CD patients. Celiac disease is also common in western India and atypical manifestations and associated conditions should be actively screened in all CD patients.

P19 – 2434: Treatable resistant occipital epilepsy: Celiac disease

Objective Celiac disease (CD) is a chronic, inflammatory autoimmune disorder caused by intolerance to ingested gluten. Increased frequency of CD has been reported in occipital lobe epilepsy. The aim of the present study is to investigate the frequency of CD among children followed up due to epilepsy and diagnosed with epileptic activity in the occipital lobe in at least one electroencephalography (EEG) test. Methods For this research, 90 pediatric epilepsy patients with epileptic activity in the occipital lobe were enrolled in the study group, while the control group comprised of 100 healthy children. In addition to the EEG examination, tissue transglutaminase (tTG) antibody was determined on duodenal biopsy. Results None of the healthy children in the control group was positive in terms of the tTG antibody test used to scan CD. In the group with epileptic activity in the occipital lobe, two patients out of 90 were tTG antibody positive. The seroprevalence was 1/45 (2.22%) in this group. These two patients were diagnosed with CD based on the endoscopic duodenal biopsy. In these patients, the seizures were uncontrollable through monotherapy. Conclusion Our results showed that the prevalence of CD is observed to be higher than the normal population among the patients with occipital lobe epilepsy. Therefore, screening for CD is recommended in children with resistant epileptic activity in the occipital lobe. Those patients can respond gluten free diet and can remain seizure free without AED.

Anemia and Celiac Disease-Experience At Tertiary Care Center of Northern India

Background: Celiac disease (CD), is a chronic immune-mediated disorder of small intestine that occurs in genetically predisposed populations. It is characterized by permanent intolerance to wheat gliadins and other cereal prolamins. The epidemiology of CD has iceberg characteristics with more undiagnosed cases. The diagnosis of CD is currently based on both typical small bowel biopsy findings with clinical and serological parameters. Anemia secondary to iron, folic acid and vitamin B12 malabsorption is a common complication of celiac disease. Patients can also present with thrombocytosis, thrombocytopenia, leukopenia, venous thromboembolism, hyposplenism and IgA deficiency. Aims: This study conducted with aims to study presenting complaints of suspected cases of celiac disease and further correlate endoscopic duodenal biopsies with various clinical and serological parameters. Materials and Methods: The detailed clinical history and physical examination was done and then duodenum biopsies in hundred cases of suspected CD (on the basis of clinical and serological profile) were taken. Histopathological diagnosis was established on routine hematoxylin and eosin stained sections. The histopathological grading was performed as per modified Marsh grading. Representative section was also subjected for immunohistochemically staining with antihuman CD3 antibody for evaluating intraepithelial lymphocytes. Comparison of these grades with the serological (anti tTG levels) and other clinical parameters (symptoms, weight, endoscopy and hemoglobin levels) were done. These data were subsequently analyzed using SPSS 20.0 software. Chi square test and other relevant statistics were used to assess the relationship between two variables. P-value less than 0.05 was accepted as statistically significant. Results and Conclusions: Majority of patients presented with typical gastrointestinal symptoms and anemia and significantly correlated with higher Marsh grades (p=0.0326) but atypical symptoms can be the primary presentation of the disease. Patients with higher serum anti-tTG levels, have a high-degree probability of duodenal damage. Anti-tTG levels have conclusively been proven to correlate with increasing histological grades (p=0.005).

Are alterations of tight junctions at molecular and ultrastructural level different in duodenal biopsies of patients with celiac disease and Crohn's disease?

Abnormalities of transmembrane and cytoplasmic proteins of tight junctions (TJ) have been implicated in pathogenesis of both celiac (CeD) and Crohn's diseases (CD). Since disease pathogenesis in CeD and CD are different, we planned to study if there is any differential expression pattern of TJ marker proteins and ultrastructural changes, respectively, in duodenal villi vs crypts. Endoscopic duodenal biopsies from treatment naïve patients with CeD (n = 24), active CD (n = 28), and functional dyspepsia (as controls, n = 15), both at baseline and 6 months after treatment, were subjected to light microscopic analysis (modified Marsh grading); immune-histochemical staining and Western blot analysis to see the expression of key TJ proteins [trans-membrane proteins (claudin-2, claudin-3, claudin-4, occludin, and JAM) and cytoplasmic protein (ZO-1)]. Transmission electron microscopy and image analysis of the TJs were also performed. There was significant overexpression of claudin-2 (pore-forming) and occludin (protein maintaining cell polarity) with under-expression of claudin-3 and claudin-4 (pore-sealing proteins) in treatment naïve CeD and active CD with simultaneous alteration in ultrastructure of TJs such as loss of penta-laminar structure and TJ dilatation. Normalization of some of these TJ proteins was noted 6 months after treatment. These changes were not disease specific and were not different in duodenal villi and crypts. Overexpression of pore-forming and under-expression of pore-sealing TJ proteins lead to dilatation of TJ. These changes are neither disease specific nor site specific and the end result of mucosal inflammation.

Olmesartan-associated enteropathy: results of a national survey.

Recently, a new enteropathy has been described: olmesartan-associated enteropathy. However, the association has been questioned: a phase 3 trial and a cohort study found no association between gastrointestinal events and olmesartan. To collect French cases of sartan-associated enteropathy to describe further this entity, confirm or refute causality, and determine if the association exists with other sartans. French gastroenterologists were invited to report cases of sartan-associated enteropathy and collect clinical, biological and histological data. Patients with diarrhoea and histological duodenal abnormalities were included. Thirty-six patients with olmesartan-associated enteropathy were reported, including 32 with villous atrophy and four without. There was only one patient with irbesartan-associated enteropathy. None of the patients died. Patients with villous atrophy had diarrhoea, vomiting, renal failure, hypokalaemia, body weight loss and hypoalbuminaemia. Thirty-one patients were hospitalised; four required intensive care. Anti-transglutaminase and anti-enterocyte antibodies were negative; anti-nuclear antibodies were positive (9/11). Endoscopic duodenal biopsies showed villous atrophy (32/32) and polyclonal intra-epithelial CD3+CD8+ lymphocytosis (11/11). Exactly, 14/15 patients responded to steroids and/or immunosuppressants, prescribed because of suspected autoimmune enteropathy. Ten olmesartan interruptions were followed by reintroductions before steroids or immunosuppressants. Interruptions were followed by remissions (9/10), but reintroductions were followed by relapses (9/9). Twenty-nine patients were in remission since olmesartan interruption, including 26 without immunosuppressants. Patients with normal villi had similar clinical characteristics, but mild histological abnormalities (intra-epithelial lymphocytosis and lamina propria lymphocytic infiltration). Olmesartan causes a severe and immune-mediated enteropathy, with or without villous atrophy. Enteropathy associated with other sartans seems to be very rare.

Tu2012 Impact of a 2-Week Very Low Calorie Diet (VLCD) on Glucose Sensing, Absorption, Transporters, Incretin Hormones and Glycemia in Morbidly Obese Humans

We showed that glucose absorption is accelerated in the proximal intestine of morbidly obese humans, associated with increased expression of sodium dependent glucose co-transporter 1 (SGLT1), an altered incretin profile, hyperinsulinemia and hyperglycemia. This study aimed to examine the effects of energy restriction on glucose absorption, expression of intestinal glucose transporters and sweet taste receptors (STR), incretin hormone responses and glycemia in the morbidly obese. Methods: 10 non-diabetic, morbidly obese subjects (2M:8F; 45±3yrs, BMI: 46±3kg/m2) were studied before and after a 2-week VLCD (750kcal/day). On each occasion, endoscopic duodenal biopsies were collected before and after intraduodenal glucose infusion (30g glucose over 30 min, with 3g 3-O-methylglucose (3-OMG) to estimate glucose absorption). Blood glucose and plasma concentrations of 3-OMG, glucosedependent insulinotropic polypeptide (GIP), glucagon-like peptide-1 (GLP-1), and insulin were measured over 240 min. Absolute expression of SGLT-1, GLUT2 and STR (T1R2) transcripts was quantified by PCR. Results After 2 weeks of VLCD, body weight (-5.6±0.5kg, P<0.001), HbA1c (-0.32±0.08%, P=0.001), fasting blood glucose (-0.5±0.1mmol/L, P=0.02) and fasting expression of T1R2 (-54±22%, P=0.03), SGLT1 (-30±7%, P=0.004) and GLUT2 (-50±15%, P=0.008) were lower than at baseline. Prior to VLCD, intra-duodenal glucose had no impact onT1R2, SGLT-1 and GLUT2 expression, but after VLCD, intra-duodenal glucose stimulated increased expression of T1R2 (45±30%, P=0.03) and GLUT2 (57±14%, P=0.003). The blood glucose (P=0.002), plasma GIP (P=0.03) and plasma insulin (P=0.002) responses to intra-duodenal glucose were all reduced after VLCD, while plasma 3-OMG and GLP-1 concentrations were unchanged. CONCLUSIONS: The improvement in glycemic control after short-term VLCD in morbid obesity is most likely mediated by reduced insulin resistance from weight loss, but not via a reduction in intestinal glucose absorption or an increased incretin response. Although VCLD reduces the fasting expression of both STR and glucose transporters, these increase rapidly on exposure to glucose. Further studies with inhibitors of STR and/or glucose transporters are warranted to determine whether the changes in receptor expressional dynamics are responsible for the observed incretin responses.

Tu2013 A Short Bowel Syndrome Rodent Model Mimicking the Human Pathology Results in Increased AgRP/NPY and Decreased POMC/TRH Expression in the Hypothalamus

We showed that glucose absorption is accelerated in the proximal intestine of morbidly obese humans, associated with increased expression of sodium dependent glucose co-transporter 1 (SGLT1), an altered incretin profile, hyperinsulinemia and hyperglycemia. This study aimed to examine the effects of energy restriction on glucose absorption, expression of intestinal glucose transporters and sweet taste receptors (STR), incretin hormone responses and glycemia in the morbidly obese. Methods: 10 non-diabetic, morbidly obese subjects (2M:8F; 45±3yrs, BMI: 46±3kg/m2) were studied before and after a 2-week VLCD (750kcal/day). On each occasion, endoscopic duodenal biopsies were collected before and after intraduodenal glucose infusion (30g glucose over 30 min, with 3g 3-O-methylglucose (3-OMG) to estimate glucose absorption). Blood glucose and plasma concentrations of 3-OMG, glucosedependent insulinotropic polypeptide (GIP), glucagon-like peptide-1 (GLP-1), and insulin were measured over 240 min. Absolute expression of SGLT-1, GLUT2 and STR (T1R2) transcripts was quantified by PCR. Results After 2 weeks of VLCD, body weight (-5.6±0.5kg, P<0.001), HbA1c (-0.32±0.08%, P=0.001), fasting blood glucose (-0.5±0.1mmol/L, P=0.02) and fasting expression of T1R2 (-54±22%, P=0.03), SGLT1 (-30±7%, P=0.004) and GLUT2 (-50±15%, P=0.008) were lower than at baseline. Prior to VLCD, intra-duodenal glucose had no impact onT1R2, SGLT-1 and GLUT2 expression, but after VLCD, intra-duodenal glucose stimulated increased expression of T1R2 (45±30%, P=0.03) and GLUT2 (57±14%, P=0.003). The blood glucose (P=0.002), plasma GIP (P=0.03) and plasma insulin (P=0.002) responses to intra-duodenal glucose were all reduced after VLCD, while plasma 3-OMG and GLP-1 concentrations were unchanged. CONCLUSIONS: The improvement in glycemic control after short-term VLCD in morbid obesity is most likely mediated by reduced insulin resistance from weight loss, but not via a reduction in intestinal glucose absorption or an increased incretin response. Although VCLD reduces the fasting expression of both STR and glucose transporters, these increase rapidly on exposure to glucose. Further studies with inhibitors of STR and/or glucose transporters are warranted to determine whether the changes in receptor expressional dynamics are responsible for the observed incretin responses.

579 Accelerated Glucose Absorption in Proximal Intestine and Its Relationship to Glucose Transporters, Incretin Hormones and Glycaemia in Morbidly Obese Humans: the “X-Factor” of the Foregut Theory?

Glucose absorption in the small intestine is mediated by sodium dependent glucose cotransporter 1 (SGLT-1) and glucose transporter-2 (GLUT2), and is potentially linked to sweet taste receptor (STR) signaling and incretin hormone secretion. Both glucose absorption and expression of SGLT-1 are increased in obese rats, but human data is lacking. This study aimed to examine intestinal glucose absorption inmorbidly obese humans, and its relationship to glycemia, incretin responses, SGLT-1, GLUT2, and STR expression. Methods: 17 nondiabetic, morbidly obese subjects (5M:12F; 45 ± 3yrs, BMI: 48 ± 4kg/m2) and 11 lean controls (10M:1F; 44 ± 6yrs, BMI: 25 ± 1kg/m2) underwent endoscopic duodenal biopsies prior to intraduodenal glucose infusion (30g glucose over 30 min, with 3g 3-O-methylglucose (3-OMG) to estimate glucose absorption). Blood glucose and plasma concentrations of 3OMG, glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide-1 (GLP1), insulin, and glucagon were measured over 240 min. Absolute expression of SGLT-1, GLUT2 and STR (T1R2) transcripts was quantified by PCR. Results: Both the rate of glucose absorption, as assessed by the rise in plasma 3-OMG concentrations (P<0.001) and blood glucose concentrations (P<0.0001) were substantially greater in obese than lean subjects (Fig AB Fig C), but not GLUT2 or T1R2, was higher in the obese than lean subjects, and was related to peaked plasma 3OMG (r=0.61, P=0.01). CONCLUSIONS: Glucose absorption in the proximal intestine is (i) accelerated in morbid obesity, (ii) associated with an incretin profile that potentially promotes both hyperinsulinemia and hyperglycemia, and (iii) associated with increased expression of SGLT-1. These novel findings suggest that accelerated glucose absorption in the proximal gutmay be the X-factor accounting for the foregut theory of obesity and diabetes.

580 Ezetimibe Modulates Endogenous LXR Ligands to Regulate Intestinal LDLR Receptors via IDOL

Glucose absorption in the small intestine is mediated by sodium dependent glucose cotransporter 1 (SGLT-1) and glucose transporter-2 (GLUT2), and is potentially linked to sweet taste receptor (STR) signaling and incretin hormone secretion. Both glucose absorption and expression of SGLT-1 are increased in obese rats, but human data is lacking. This study aimed to examine intestinal glucose absorption inmorbidly obese humans, and its relationship to glycemia, incretin responses, SGLT-1, GLUT2, and STR expression. Methods: 17 nondiabetic, morbidly obese subjects (5M:12F; 45 ± 3yrs, BMI: 48 ± 4kg/m2) and 11 lean controls (10M:1F; 44 ± 6yrs, BMI: 25 ± 1kg/m2) underwent endoscopic duodenal biopsies prior to intraduodenal glucose infusion (30g glucose over 30 min, with 3g 3-O-methylglucose (3-OMG) to estimate glucose absorption). Blood glucose and plasma concentrations of 3OMG, glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide-1 (GLP1), insulin, and glucagon were measured over 240 min. Absolute expression of SGLT-1, GLUT2 and STR (T1R2) transcripts was quantified by PCR. Results: Both the rate of glucose absorption, as assessed by the rise in plasma 3-OMG concentrations (P<0.001) and blood glucose concentrations (P<0.0001) were substantially greater in obese than lean subjects (Fig AB Fig C), but not GLUT2 or T1R2, was higher in the obese than lean subjects, and was related to peaked plasma 3OMG (r=0.61, P=0.01). CONCLUSIONS: Glucose absorption in the proximal intestine is (i) accelerated in morbid obesity, (ii) associated with an incretin profile that potentially promotes both hyperinsulinemia and hyperglycemia, and (iii) associated with increased expression of SGLT-1. These novel findings suggest that accelerated glucose absorption in the proximal gutmay be the X-factor accounting for the foregut theory of obesity and diabetes.

Prevalence of resistant occipital lobe epilepsy associated with celiac disease in children

Celiac disease (CD) is a chronic, inflammatory autoimmune disorder caused by intolerance to ingested gluten. Increased frequency of CD has been reported in occipital lobe epilepsy. The aim of the present study is to investigate the frequency of CD among children followed up due to epilepsy and diagnosed with epileptic activity in the occipital lobe in at least one electroencephalography (EEG) test. For this research, 90 pediatric epilepsy patients with epileptic activity in the occipital lobe were enrolled in the study group, while the control group comprised of 100 healthy children. In addition to the EEG examination, tissue transglutaminase (tTG) antibody was determined on duodenal biopsy. None of the healthy children in the control group was positive in terms of the tTG antibody test used to scan CD. In the group with epileptic activity in the occipital lobe, two patients out of 90 were tTG antibody positive. The seroprevalence was 1/45 (2.22 %) in this group. These two patients were diagnosed with CD based on the endoscopic duodenal biopsy. In these patients, the seizures were uncontrollable through monotherapy. Our results showed that the prevalence of CD is observed to be higher than the normal population among the patients with occipital lobe epilepsy. This type of seizure disorder seems to be more resistant to monotherapy, compared with other types of occipital epilepsy. Therefore, screening for CD is recommended in children with resistant epileptic activity in the occipital lobe.

Enteral glutamine infusion modulates ubiquitination of heat shock proteins, Grp-75 and Apg-2, in the human duodenal mucosa

Glutamine, the most abundant amino acid in the human body, plays several important roles in the intestine. Previous studies showed that glutamine may affect protein expression by regulating ubiquitin-proteasome system. We thus aimed to evaluate the effects of glutamine on ubiquitinated proteins in human duodenal mucosa. Five healthy male volunteers were included and received during 5 h, on two occasions and in a random order, either an enteral infusion of maltodextrins alone (0.25 g kg(-1) h(-1), control), mimicking carbohydrate-fed state, or maltodextrins with glutamine (0.117 g kg(-1) h(-1), glutamine). Endoscopic duodenal biopsies were then taken. Total cellular protein extracts were separated by 2D gel electrophoresis and analyzed by an immunodetection using anti-ubiquitin antibody. Differentially ubiquitinated proteins were then identified by liquid chromatography-electrospray ionization MS/MS. Five proteins were differentially ubiquitinated between control and glutamine conditions. Among these proteins, we identified two chaperone proteins, Grp75 and hsp74. Grp75 was less ubiquitinated after glutamine infusion compared with control. In contrast, hsp74, also called Apg-2, was more ubiquitinated after glutamine. In conclusion, we provide evidence that glutamine may regulate ubiquitination processes of specific proteins, i.e., Grp75 and Apg-2. Grp75 has protective and anti-inflammatory properties, while Apg-2 indirectly regulates stress-induced cell survival and proliferation through interaction with ZO-1. Further studies should confirm these results in stress conditions.

Ankilozan Spondilitli Bir Hastada Strongyloides stercoralis: Olgu Sunumu

Strongyloidiasis is a nematode-borne disease caused by several Strongyloides species. This case was presented in order to indicate Strongyloidosis in immunocompromised patients with several clinical findings. A fifty-five year old male patient on corticosteroid medication for a long time because of ankylosing spondylitis was on infliximab medication for 5 years. He presented with swelling of his right foot for ten days, right shoulder stiffness and low back pain. The presence of anaemia was remarkable. S. stercoralis was reported in histological examination of endoscopic duodenal biopsy specimen. Peripheral blood smear showed 68.4% neutrophils, 17% lymphocytes, 7.5% monocytes, and 6.7% (normal range 2%-6.2) eosinophils. The level of IgE was raised: 285IU/mL (normal range 5-120IU/mL). A large number of S. stercoralis larvae were detected upon stool examination with saline and iodine mounts and the formaldehyde ether concentration method. After treatment with two cure albendazole 400 mg/day for 7 days, S. stercoralis larvae were not detected in stool examination. It is interesting that response to treatment was not observed on the first cure and the recovery was seen on the second cure. We suggest that hyperinfections should be taken into consideration in the diagnosis and treatment of immunocompromised patients with several complaints so that life-threatening effects of the nematode may be prevented.

A Comprehensive Pathological Survey of Duodenal Biopsies from Dogs with Diet‐Responsive Chronic Enteropathy

The detailed pathological phenotype of diet-responsive chronic enteropathy (CE) and its modulation with dietary therapy remain poorly characterized. Key mucosal lesions of diet-responsive CE resolve with dietary therapy. This was a prospective observational study of 20 dogs with diet-responsive CE. Endoscopic duodenal biopsies collected before and 6 weeks after the start of a dietary trial were assessed by means of qualitative and quantitative histopathological, immunohistochemical, and ultrastructural criteria. Control duodenal biopsies were obtained from 10 healthy Beagle dogs on 1 occasion. Compared with control dogs, the CE dogs had higher villus stunting scores and higher overall WSAVA scores, a lower villus height-to-width ratio, and higher lamina propria density of eosinophils. The CE dogs also had ultrastructural lesions of the mitochondria and brush border. In common with other studies in which the disease and control populations are not matched for breed, age, sex, and environment, these comparisons should be interpreted with caution. Comparing biopsies collected at presentation and 6 weeks after starting the dietary trial, mean lamina propria mononuclear cell score and lamina propria densities of eosinophils and mononuclear cells decreased. Dietary therapy also improved ultrastructural lesions of the mitochondria and brush border, eliciting a decrease in intermicrovillar space and an increase in microvillus height. In dogs with diet-responsive CE, the remission of clinical signs with dietary therapy is associated with subtle decreases in lamina propria density of eosinophils and mononuclear cells, and resolution of ultrastructural lesions of the enterocyte.

Extracellular matrix proteins and displacement of cultured fibroblasts from duodenal biopsies in celiac patients and controls

BackgroundCeliac disease (CD) is mainly characterised by villous atrophy and mucosal architectural rearrangement. The fibroblasts (FBs) are the most abundant mesenchymal cell type in the intestinal mucosa and are responsible for both the architectural arrangement of the villi and the formation of the extracellular matrix (ECM). This study aimed at the evaluation of both the intracellular distribution of different proteins involved in ECM and FBs characterisation, and the cellular displacement of primary FBs obtained from duodenal endoscopic biopsies of healthy subjects and celiac patients.MethodsPrimary healthy and celiac duodenal FBs were evaluated by means of immuno-fluorescence assay for collagen type I and IV, fibronectin, actin, alpha-Smooth Muscle Actin (alpha-SMA), Fibroblast Surface Protein (FSP) and transglutaminase type 2 (TG2). The geometric indexes of the fluorescence signals were investigated by image analysis software (Image J, NIH). Both morphology and kinetic were evaluated during a 72 hours time course movie. TG2 medium activity was evaluated by means of ELISA.ResultsAll the cells examined were immunopositive for FSP, alpha-SMA, actin, collagen I, collagen IV and TG2. CD cells showed a signet collagen-I and collagen-IV pattern, as compared to the controls being characterised by a spindle geometry. Moreover, the collagen signals in CD FBs showed a significantly higher circularity index (major orthogonal diameter ratio) than the controls (p < 0.0001), whereas the perimeter and area ratio were significantly lower (p < 0.0001). The TG2 signal had a decreased area (p < 0.05), but a two-fold increased medium activity. The time course highlighted a reduction of the displacement of CD FBs.ConclusionsThe isolated primary CD FBs showed a different collagen and TG2 pattern of distribution associated with a different cellular displacement. The reasons for such CD cell peculiar characteristics are yet unknown but they might represent a factor in the progression of the intestinal damage.

Frequency of Celiac Disease in Attention‐deficit/Hyperactivity Disorder

Although it is well known that celiac disease (CD) is associated with neurologic disorders, association with psychiatric problems is not well defined. In this report, we aimed to detect CD prevalence in patients with attention-deficit hyperactivity disorder (ADHD). A total of 362 patients between the ages 5 and 15 years with the diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria and 390 sex- and age-matched healthy children were included in the present study. Serum levels of tissue transglutaminase (tTg) immunoglobulin (Ig) A and IgG were studied in both groups. Serum IgA levels were also studied in patients with positive tTG IgG for the exclusion of selective IgA deficiency. Endoscopic duodenal biopsy was provided in seropositive patients, whose parents approved the procedure. Biopsy samples were evaluated according to Marsh-Oberhuber classification. tTg IgA was positive in 4 patients with ADHD (1.1%). Endoscopic duodenal biopsy was suggestive of CD in one of them (0.27%). tTg IgA was positive in 3 of control group patients (0.8%). Duodenal biopsy of the only patient from control group, who underwent upper gastrointestinal endoscopy, revealed normal intestinal mucosa. The seropositivity rates for CD were found similar in ADHD and control groups. Thus, neither routine screening for CD nor empirical recommendation of gluten-free diet seems necessary in children with ADHD.

Enteral delivery of proteins stimulates protein synthesis in human duodenal mucosa in the fed state through a mammalian target of rapamycin–independent pathway

Glutamine modulates duodenal protein metabolism in fasted healthy humans, but its effects in a fed state remain unknown. We aimed to assess the effects of either glutamine or an isonitrogenous protein mixture on duodenal protein metabolism in humans in the fed state. Twenty-four healthy volunteers were randomly included in 2 groups. Each volunteer was studied on 2 occasions in a random order and received, during 5 h, either an enteral infusion of maltodextrins alone (0.25 g · kg⁻¹ · h⁻¹; both groups) that mimicked a carbohydrate fed state or maltodextrins with glutamine (group 1) or an isonitrogenous (22.4 mg N · kg⁻¹ · h⁻¹) protein powder (group 2). Simultaneously, a continuous intravenous infusion of ¹³C-leucine and ²H₅-phenylalanine (both 9 μmol · kg⁻¹ · h⁻¹) was performed. Endoscopic duodenal biopsies were taken. Leucine and phenylalanine enrichments were assessed by using gas chromatography-mass spectrometry in duodenal proteins and the intracellular free amino acids pool to calculate the mucosal fractional synthesis rate (FSR). Proteasome proteolytic activities and phosphokinase expression were assessed by using specific fluorogenic substrates and macroarrays, respectively. The FSR and proteasome activity were not different after the glutamine supply compared with after maltodextrins alone. In contrast, the FSR increased (1.7-fold increase; P < 0.05) after protein-powder delivery without modification of total proteasome activity. The protein powder increased insulinemia, PI3 kinase, and erk phosphorylation but did not affect the mammalian target of rapamycin (mTOR) pathway and mitogen-activated protein kinase signal-integrating kinase 1 phosphorylation. A trend for an increase of eukaryotic translation initiation factor 4E phosphorylation was observed (P = 0.07). In the carbohydrate fed state, enteral proteins but not glutamine increased duodenal protein synthesis through an mTOR independent pathway in humans.

Detection of adult celiac disease with duodenal screening biopsies over a 30-year period.

Serological studies suggest that celiac disease may be present in approximately 0.5% to 1% of the North American population. Screening data based on small intestinal biopsy performed during routine endoscopic evaluations are not available. Patients referred between January 1982 and December 2011 for evaluation of gastrointestinal symptoms and requiring elective investigative upper endoscopic evaluation underwent duodenal biopsies to determine whether changes of adult celiac disease were present. A total of 9665 patients, including 4008 (41.5%) males and 5657 (68.5%) females, underwent elective endoscopies and duodenal biopsies. Of these, 234 (2.4%) exhibited changes of celiac disease including 73 males (1.8%) and 161 females (2.8%). During the first 20 years, the number of biopsy-positive patients in five-year intervals progressively decreased and, subsequently, during the next 10 years, the number progressively increased. Celiac disease is far more common in specialist practice than has been suggested in the evaluation of healthy populations using serological screening studies. Endoscopic duodenal biopsy is an important method of identifying underlying celiac disease and should be routinely considered in all patients undergoing an elective endoscopic evaluation. Noninherited factors, possibly environmental, may play a role in the appearance of biopsy-defined celiac disease and alter detection over time.

An enteral leucine supply modulates human duodenal mucosal proteome and decreases the expression of enzymes involved in fatty acid beta-oxidation

Leucine is well known to regulate protein metabolism in muscle. We recently reported that enteral leucine infusion decreased proteasome activity in human duodenal mucosa and enhanced intestinal cell proliferation, but its effects on gut proteome remain unknown. Therefore, we aimed to assess the effects of an enteral leucine infusion on the whole proteome of duodenal mucosa. In this work, 5 healthy volunteers received for 5h, on 2 occasions and in random order, an enteral supply of maltodextrins (0.25 g kg(-1) h(-1)) or maltodextrins supplemented with leucine (0.035 g kg(-1) h(-1)). At the end of infusion, endoscopic duodenal biopsy samples were collected and analyzed by 2D-PAGE. Eleven protein spots were differentially and significantly (P<0.05) expressed in response to the leucine-supplemented maltodextrins compared with maltodextrins alone. Forty percent of identified proteins by mass spectrometry were located in mitochondria. Four proteins were involved in lipid metabolism: HADHA, ACADVL and CPT2 expressions were reduced, whereas FABP1 expression was increased. In addition, the expression of DHA kinase involved in glycerol metabolism was also downregulated. Finally, leucine supplementation altered the duodenal mucosal proteome by regulating the expression of several enzymes mainly involved in lipid metabolism. These results suggest that leucine supplementation may slowdown fatty acid beta-oxidation in human duodenal mucosa.