Overt Celiac Disease Research Articles

A 2-year follow-up study in children with positive coeliac disease-specific serum antibodies and architecturally normal small intestinal mucosa

Background and aim. In recent years the presence of antiendomysium EMA) and anti tissue transglutaminase 2 (anti-TG2) with a normal duodenal ucosa has been defined as potential coeliac disease (CD). Aim of our study as to characterise the natural history of potential CD. Patients.Two cohorts of children were recruited: 30 in the Pediatric Unit f Cava de’ Tirreni Hospital and 32 in the Department of Pediatrics at the niversity Federico II in Naples. Forty-two patients were Marsh T0 and 20 1. In all serum anti-TG2 and/or EMA were positive. All carried HLA DQ2 nd/or DQ8. The mean age was 6.7 years (range: 1.6–14.6). Methods. Growth and nutritional parameters, serology, autoimmunity, aecal calprotectin and intestinal permeability were assessed every 6 months. atients with persistent EMA and/or anti-TG2 even if not symptomatic were e-biopsied after 2 years. Results. The incidence of potential CD was 9.5–12%. Eight patients ere symptomatic and began a gluten-free diet. Symptoms resolved in 3/8 atients. All other patients had a normal daily gluten intake.13/62 potential D patients were first-degree relatives, 12/62 were affected by autoimmune iseases and 3/62 were asymptomatic. In all other cases gastrointestinal omplaints resolved with appropriate medical therapy. 33/54 patients entered the follow-up. After 2 years 17/33 patients were erologically negative, but two developed autoimmune disorders (diabetes, hyroiditis). During the follow-up biopsies were taken from 7 patients all MA and/or anti-TG2 positive. In 4 patients the second biopsy after 2 years nd in one patient the third biopsy after 5 years was still normal. Two patients eveloped partial villous atrophy, one at the second biopsy after 2 years and nother at the third biopsy after 5 years. Clinical and nutritional evaluation as normal in all patients except in one of the two patients who developed illous atrophy. In 9 patients we correlated faecal calprotectin, intestinal pereability and serology. Faecal calprotectin and intestinal permeability were ignificantly correlated (R= 0.71). Interestingly, in patients with positive MA and anti-TG2 >10 UA/ml (nv < 5) intestinal permeability and faecal alprotectin were abnormal; furthermore, these patients remained serologially positive during the follow-up and one developed partial villous atrophy. n patients with negative EMA and anti-TG2 < 10 intestinal permeability and aecal calprotectin were normal; during the follow-up they remained seroogically negative. Conclusions. Incidence of potential CD is increasing in the last years 3.8–17%). This condition is mainly seen in first-degree relatives (20%) and atients with autoimmune disorders (19%). In our cohort EMA and anti-TG2 eturned to normal in 50% of cases, but 6% developed other autoimmune iseases. Duodenal mucosa can remain normal for several years despite he presence of serum EMA and anti-TG2. Finally, the presence of both MA and anti-TG2 in addition to abnormal intestinal permeability, clinical ymptoms and faecal calprotectin seems to be strongly predictive of the volution to overt coeliac disease.

Celiac disease.

Celiac disease is a chronic intestinal disease caused by intolerance to gluten. It is characterized by immune-mediated enteropathy, associated with maldigestion and malabsorption of most nutrients and vitamins. In predisposed individuals, the ingestion of gluten-containing food such as wheat and rye induces a flat jejunal mucosa with infiltration of lymphocytes. The main symptoms are: stomach pain, gas, and bloating, diarrhea, weight loss, anemia, edema, bone or joint pain. Prevalence for clinically overt celiac disease varies from 1:270 in Finland to 1:5000 in North America. Since celiac disease can be asymptomatic, most subjects are not diagnosed or they can present with atypical symptoms. Furthermore, severe inflammation of the small bowel can be present without any gastrointestinal symptoms. The diagnosis should be made early since celiac disease causes growth retardation in untreated children and atypical symptoms like infertility or neurological symptoms. Diagnosis requires endoscopy with jejunal biopsy. In addition, tissue-transglutaminase antibodies are important to confirm the diagnosis since there are other diseases which can mimic celiac disease. The exact cause of celiac disease is unknown but is thought to be primarily immune mediated (tissue-transglutaminase autoantigen); often the disease is inherited. Management consists in life long withdrawal of dietary gluten, which leads to significant clinical and histological improvement. However, complete normalization of histology can take years.

Autoantibody targeting of brain and intestinal transglutaminase in gluten ataxia

To investigate the presence of autoantibody deposition against type 2 tissue transglutaminase (TG2; a reliable marker of the whole spectrum of gluten sensitivity) in the jejunal tissue and brain of patients with gluten ataxia and in control subjects. The authors evaluated jejunal biopsy samples from nine patients with gluten ataxia and seven patients with other causes of ataxia for the presence of TG2-related immunoglobulin deposits using double-color immunofluorescence. Autopsy brain tissue from one patient with gluten ataxia and one neurologically intact brain were also studied. IgA deposition on jejunal TG2 was found in the jejunal tissue of all patients with gluten ataxia and in none of the controls. The intestinal IgA deposition pattern was similar to that seen in patients with overt and latent celiac disease and in those with dermatitis herpetiformis. Widespread IgA deposition around vessels was found in the brain of the patient with gluten ataxia but not the control brain. The deposition was most pronounced in the cerebellum, pons, and medulla. Anti-tissue transglutaminase IgA antibodies are present in the gut and brain of patients with gluten ataxia with or without an enteropathy in a similar fashion to patients with celiac disease, latent celiac disease, and dermatitis herpetiformis but not in ataxia control subjects. This finding strengthens the contention that gluten ataxia is immune mediated and belongs to the same spectrum of gluten sensitivity as celiac disease and dermatitis herpetiformis.

PRODUCTION OF ANTITRANSGLUTAMINASE AUTOANTIBODIES IN THE JEJUNUM OF PATIENTS WITH TYPE1 DIABETES

Summary: An association between type 1 diabetes mellitus (T1DM) and celiac disease (CD) has been reported since a long time. The prevalence of CD in T1DM is as high as 1.3%-16.4%, and nearly 20% of T1DM children has been shown to react to rectal instillation of gliadin. A hallmark of CD are the autoantibodies to tissue transglutaminase (tTG). By the Phage Display technique we previously demonstrated that the site of production of tTGautoantibodies is the intestine. Aim: The aim of this study was to investigate the presence of IgA anti-tTG antibodies in jejunal biopsies from patients with T1DM patients who did not show serological markers of CD. Materials and Methods: We made antibody libraries from the jejuna of 7 patients with T1DM (4 EMA/tTG+, 3 EMA/tTG−). We first adopted the One Step Cloning Strategy: only the genes belonging to the VH5 family, which has been previously associated with the anti-tTG antibody response, were cloned. In a second stage the entire antibody repertoire from 2 EMA/tTG + and 2 negative was cloned. Results: The VH5 libraries from EMA/tTG + patients were highly positive for the presence of scFv anti-tTG, whereas those from EMA/tTG-patients were not. Surprisingly, the htTG selection of the complete antibody repertoire libraries revealed to be strongly positive also inpatients EMA/tTG−. The positive clones were subjected to BstnI restriction analysis (fingerprinting) and sequencing. The fingerprinting was highly variable and the sequencing showed that the scFv anti-tTG, in EMA/tTG-patients, belong prevalently to the VH3 gene family. A possible gluten-related condition was confirmed by the isolation of anti-gliadin scFv in EMA/tTG- patients. Conclusion: Phage Display libraries from T1DMpatients revealed the intestinal expression of anti-tTG antibodies also in absence of peripheral antibodies. T1DM patients EMA/tTG-produce anti-tTG antibodies prevalently with the VH3 gene family. It will be interesting to evaluate the percentage of T1DM patients EMA/tTG-producing intestinal anti-tTG antibodies and their possible progression toward an overt CD.

Natural history of transglutaminase autoantibodies and mucosal changes in children carrying HLA-conferred celiac disease susceptibility

The natural history of the appearance and fate of transglutaminase autoantibodies (TGAs) and mucosal changes in children carrying HLA-conferred celiac disease (CD) risk remains obscure. The aim of this study was to investigate the sequence of events leading to overt CD by retrospective analysis of TGA values in serum samples collected frequently from genetically susceptible children since birth or early childhood. A total of 1101 at-risk children were recruited in the study. A duodenal biopsy was recommended to all TGA-positive children and performed if parental consent was obtained. During up to 8 years of follow-up, 35 of the cohort children developed TGAs, the youngest at age 1.3 years. After age 1.3 years the annual TGA seroconversion rate was constantly around 1% at least until age 6 years. However, 18 of the 35 TGA-positive children (51%) lost TGAs, without any dietary manipulation. A further 7 children were IgA deficient; of these children, 2 developed IgG antigliadin antibodies (IgG-AGA). Only 13 of the 21 children (62%) who had duodenal biopsies had villous atrophy. The time that passed since emergence of TGAs failed to predict the biopsy findings. Only one of the children with TGAs and both of the IgA-deficient children with IgG-AGA had noticeable abdominal symptoms. TGAs appear in children at a constant rate after 1 year of age until at least the age of 6 years. Over half of the children loose TGA without gluten exclusion, challenging TGA positivity-based CD prevalence estimates. In symptom-free children, a requirement of two consecutive TGA-positive samples taken >or=3 months apart before performing a duodenal biopsy might diminish the number of unnecessary intestinal biopsies.

Accuracy of ultrasonography in predicting celiac disease.

Various ultrasonographic (US) signs have been reported in overt celiac disease (CD). The aim of this study was to investigate the diagnostic accuracy of 6 US parameters in predicting CD. One hundred sixty-two consecutive patients with chronic diarrhea (n=105), iron deficiency anemia (n=25), or dyspepsia (n=32) underwent anti-endomysial IgA antibody determination and duodenal biopsy. Moreover, US evaluation of 6 parameters (ie, fasting gallbladder volume, transverse diameter of small bowel loops, thickness of the small bowel wall, pattern of peristalsis, presence of free abdominal fluid, and diameter of the mesenteric lymph nodes) was done by 2 operators blind to the serological and histological findings. The pretest probability of CD was estimated to be between 5% and 10%. The percentage of agreement between US and histologic findings, the sensitivity, specificity, positive and negative likelihood ratios, and the posttest probability for positive and negative results were calculated. Celiac disease was diagnosed in 12 patients (7.4%). An increased gallbladder volume, the presence of free fluid in the abdominal cavity, and enlarged mesenteric lymph nodes showed a specificity of 96%, 96%, and 97%, respectively (95% confidence intervals [CIs], 92%-99%, 93%-99%, and 95%-99%), whereas the presence of dilated small bowel loops with increased fluid content and increased peristalsis had a sensitivity of 92% and 83%, respectively (95% CIs, 76%-100% and 62%-100%). Eleven (92%) of the 12 patients with celiac disease and 35 (23%) of the 150 patients who did not have the disease had at least 1 US sign (P=.001); all of the US signs were concomitantly present in 4 patients with CD (33%) and 1 patient without CD (0.6%) (P=.001). Ultrasonographic evaluation can accurately predict CD but its place in the diagnostic algorithm depends upon the probability of the disease in the considered population.

Lack of endoscopic visualization of intestinal villi with the “immersion technique” in overt atrophic celiac disease

Background: The endoscopic appearance of the duodenal folds can predict the presence of celiac disease. However, endoscopic alterations can be minimal and the disease can have a “patchy” distribution histopathologically. The observation that intestinal villi can be better visualized when the duodenum is filled with water led to the development of an endoscopic “immersion technique” to assess celiac disease. Methods: Endoscopy with duodenal biopsies was performed in 20 patients with malabsorption syndrome (positive for antiendomysial antibodies) and in 30 patients with reflux-like symptoms (negative for antiendomysial antibodies). Duodenal hypotonia was induced pharmacologically, water was introduced, and the mucosa was observed for the presence of villi. Photographs were obtained for subsequent analysis. The endoscopic appearance was classified from 1 (folds certainly present) to 4 (“scalloped valvulae”); villous structures were classified from 1 (definitely present) to 3 (definitely absent). Results: Celiac disease was confirmed histopathologically in all patients with positive antiendomysial antibodies. The endoscopic appearance of the duodenum with air insufflation alone had a positive predictive value for the diagnosis of celiac disease of 84% and a specificity of 87%. Visualization of villi with the “immersion technique” had a higher positive predictive value (99%) and specificity (99%). Conclusions: A lack of visualization of intestinal villi in the descending duodenum with the “immersion technique” may increase the diagnostic accuracy of endoscopy for celiac disease. This technique could also be useful for targeting duodenal biopsies. (Gastrointest Endosc 2003;57:348-51.)

Anti-alpha-gliadin antibodies (AGA) in the serum of coeliac children and controls recognize an identical collection of linear epitopes of alpha-gliadin.

Anti-gliadin antibodies can be found in the serum of patients with overt and subclinical coeliac disease, but also in that of some controls. The aim of the present study was to identify the linear epitopes of the alpha-gliadin molecule to which the humoral response is directed. Therefore, the IgG and IgA antibody reactivity against an overlapping set of synthetic peptides covering the entire sequence of alpha-gliadin was measured in the sera from patients with coeliac disease, from controls with elevated titres of anti-gliadin antibodies and from healthy children using an ELISA technique. The antibodies mainly recognize peptides derived from the N-terminal region of alpha-gliadin, containing the motif QPFXXQXPY. Reactivity was also detected against two other synthetic peptides, which do not contain this motif and represent a sequence encoded further to the C-terminal region of alpha-gliadin. Anti-gliadin antibodies in sera from patients with coeliac disease and from controls recognize the same linear epitopes. Thus, serological investigation of the specificity of these antibodies using a peptide ELISA does not allow discrimination between patients and controls.

Endoscopic visualization of intestinal villi with “immersion technique”: Sensibility, specificity and diagnostic predictive value in overt atrophic celiac disease

Endoscopic visualization of intestinal villi with “immersion technique”: Sensibility, specificity and diagnostic predictive value in overt atrophic celiac disease

Forty-Eight Hours of Biopsy Culture Improve the Sensitivity of the in Vitro Gliadin Challenge in the Diagnosis of Celiac Disease

Celiac disease (CD) is a long-life intolerance to gliadin in genetically susceptible individuals (1)(2)(3)(4)(5)(6). Despite contrary views (7), diagnosis is still based on the histologic findings of intestinal mucosal atrophy with crypt hyperplasia in individuals on a gluten-containing diet and a return to normal after a gluten-free diet (GFD). The presence of circulating anti-endomysial antibodies (EMAs) and their disappearance after GFD confirm the diagnosis (8)(9)(10). It has recently been shown that EMAs are produced by intestinal mucosa of CD patients. EMAs disappear in treated CD patients but are newly produced after in vitro exposure of intestinal biopsy samples to gliadin (11). Culture of intestinal mucosa from treated CD patients in the presence of a peptic-tryptic (PT) digest of gliadin for 24 h frequently fails to produce detectable EMAs, but it has high specificity as well as high sensitivity in overt CD (12). Our aim was to increase the sensitivity of the in vitro culture by prolonging the duration to 48 h. We also tested a new culture method in batch to ease testing. We enrolled 11 untreated, EMA-positive CD patients (5 males and 6 females; mean age, 24.7 years; age range, 17–42 years) and 29 treated CD patients (11 males and 18 females; mean age, 32.0 years; age range, 11–70 years) after at least 12 months of GFD (median length of GFD, 730 days; range, 342–4015 days) and two monthly, consecutive serum EMA tests that were negative. As disease-controls we studied 67 patients (20 males and 47 females, mean age, 35.3 years; age range, 20–50 years) with gastrointestinal diseases other than CD (42 with gastroesophageal reflux disease, 8 with ulcer disease, 3 with ulcerative colitis, 3 with Crohn disease, 2 with lymphoma, 1 with small …

Gluten sensitivity in monozygous twins: a long-term follow-up of five pairs

OBJECTIVE: The aim of this study was to investigate the role of genetic factors and the characteristics of five monozygous twin pairs with at least one member affected by gluten sensitivity. METHODS: Five pairs of monozygous female twins, of whom one or both were affected by gluten sensitivity ( i.e., celiac disease or dermatitis herpetiformis), were followed-up for 11–23 yr. RESULTS: Three pairs were concordant for celiac disease: the onset was comparable and synchronous in two pairs; in the third, one member presented an overt malabsorption syndrome, and the other developed iron deficiency anemia 10 yr later. Discordance for gluten sensitivity was found in the remaining two pairs, one of whose members was diagnosed as having, respectively, celiac disease and dermatitis herpetiformis. CONCLUSIONS: As no environmental factors were found to affect the phenotypic expression of the disease, genetic factors seem to play a major role. The presence of overt or latent celiac disease in three of the four siblings of the three concordant twins, and the association with cystic fibrosis in all three siblings of one of these families, further supports this hypothesis.

Gluten sensitivity in monozygous twins: a long-term follow-up of five pairs.

The aim of this study was to investigate the role of genetic factors and the characteristics of five monozygous twin pairs with at least one member affected by gluten sensitivity. Five pairs of monozygous female twins, of whom one or both were affected by gluten sensitivity (i.e., celiac disease or dermatitis herpetiformis), were followed-up for 11-23 yr. Three pairs were concordant for celiac disease: the onset was comparable and synchronous in two pairs; in the third, one member presented an overt malabsorption syndrome, and the other developed iron deficiency anemia 10 yr later. Discordance for gluten sensitivity was found in the remaining two pairs, one of whose members was diagnosed as having, respectively, celiac disease and dermatitis herpetiformis. As no environmental factors were found to affect the phenotypic expression of the disease, genetic factors seem to play a major role. The presence of overt or latent celiac disease in three of the four siblings of the three concordant twins, and the association with cystic fibrosis in all three siblings of one of these families, further supports this hypothesis.

Intolerance to Cereals Is Not Specific for Coeliac Disease

Abdominal complaints after ingestion of cereals are not uncommon. We assessed how reliable such a history is as a marker for the presence of overt coeliac disease, and whether we should also take into account latent coeliac disease and cereal allergy. The study group comprised 93 consecutive adults from health centres spontaneously reporting abdominal symptoms after consumption of cereals. Small bowel mucosal morphology, CD3+, alphabeta+ and gammadelta+ intraepithelial lymphocytes (IELs), HLA DQ alleles and serum IgA-class endomysial (EmA), tissue transglutaminase (tTg) and gliadin (AGA) antibodies were determined. Skin prick and patch tests and serum radioallergosorbent tests for cereals were carried out. Thirty non-coeliac adults served as biopsy controls. Eight (9%) patients had coeliac disease and one mild partial villous atrophy. Altogether 17 had an increased density of gamma delta+ IELs without atrophy. However, only seven (8%) showed evidence of latent coeliac disease, i.e. both an increase in gammadelta+ IELs and the presence of coeliac disease-type HLA. One or more of the allergy tests for cereals was positive in 19; 9 adopted a gluten-free diet and abdominal symptoms were alleviated in all. In non-coeliac patients, serum EmA and tTg tests were negative in all, whereas AGA was seen in 40%. Intolerance to cereals is not a specific sign of overt or latent coeliac disease. All experimental dietary interventions before proper diagnosis of coeliac disease are therefore to be discouraged. Allergy to cereals, on the other hand, should be considered even in adults.

Latent and potential coeliac disease.

Under the umbrella of coeliac disease (CD), or gluten-sensitive enteropathy, the concepts of silent, latent and potential CD have recently been introduced. While silent CD is marked by severe damage to the jejunal mucosa in the absence of clinical symptoms, both latent and potential CD are characterized by jejunal mucosa that would be reported as normal by most clinical pathologists in an individual on a gluten-containing diet. As opposed to potential coeliac patients, latent subjects sometimes in their life have had a flat jejunal biopsy which recovered on a gluten-free diet. Latent coeliac patients are often symptomatic; neither high titres of gliadin antibodies nor mucosal changes (including raised intraepithelial lymphocyte counts) are obligate features of latent CD, although the presence of elevated endomysial antibodies is probably the best predictor of progression towards villous atrophy. The term potential CD has been proposed for those subjects who do not have, and have never had, a jejunal biopsy consistent with overt CD, and yet have immunological abnormalities similar to those found in coeliac patients. Good markers of potential CD include the presence of serum endomysial antibodies, a high count of intraepithelial lymphocytes and subtle pathological alteration such as increased density of intraepithelial lymphocytes expressing gamma delta T cell receptor, signs of activated mucosal cell-mediated immunity, coeliac-like intestinal antibody pattern, and positive rectal gluten challenge.

Effect of gluten supplementation in healthy siblings of children with celiac disease

The clinical, functional, and histopathological effects of 18 g additional gluten intake daily for 4 wk was studied in 13 healthy siblings of Spanish children with celiac disease, including two pairs of discordant monozygotic twins. Five of the 13 children were HLA-DR identical to the celiac sibling, 5 shared only one HLA-DR antigen with the celiac sibling, and 3 had completely different HLA-DR antigens than their respective celiac brothers or sisters. Clinical evaluation and functional tests (routine blood, xylose absorption, and fecal fat excretion studies) were performed before, during, and after gluten challenge. A jejunal biopsy specimen was taken at the end of the 4-wk period of gluten supplementation. No clinical abnormalities were found during the period of the study and there was no significant decrease of xylose absorption. Fecal fat excretion studies gave normal results, both before and after gluten challenge. The high gluten diet did not lead to histopathologic abnormalities in any of the jejunal biopsy specimens, which showed a normal range of crypt to villus ratio and surface-cell height. The present results do not support the view that excessive gluten intake is toxic for individuals who are genetically predisposed but do not have overt celiac disease. The findings also suggest that other factors besides HLA-DR antigens and gluten intake are important for expression of the disease.

GLUTEN-INDUCED MUCOSAL CHANGES IN SUBJECTS WITHOUT OVERT SMALL-BOWEL DISEASE

Five normal volunteers, six normal first degree relatives of coeliac patients, and four patients with altered immunity (two primary biliary cirrhosis, one common variable immune deficiency, one immunoglobulin A deficiency) were studied both before and after a six week period during which their normal diet was supplemented by 40 g of gluten per day. Administration of the high gluten diet produced significant architectural changes in the jejunal mucosa of both the normal relatives of coeliac patients and the patients with altered immunity (p<0.01). In some cases changes amounted to severe partial villous atrophy. A significant increase in intraepithelial lymphocytes was also observed in the normal relatives of coeliac patients and in the normal volunteers (p<0.05); patients with altered immunity had high intraepithelial lymphocyte counts both before and after the high gluten diet. A significant decrease in xylose absorption occurred in the relatives of coeliac patients and in the normal volunteers (p<0.05). Two normal relatives and one patient with altered immunity had diarrhoea, which ceased on return to a normal diet. These findings indicate that excessive gluten intake can induce changes in the jejunal mucosal architecture in susceptible individuals who do not have overt coeliac disease.