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ESPGHAN Guidelines for Diagnosing Coeliac Disease 2020

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Briefly noted: S Husby et al. JPGN 2020; 70: 141-56.

Link to document: ESPGHAN Guidelines for Diagnosing Coeliac Disease 2020

Key recommendations for diagnosing celiac disease (CD):

  • If CD is suspected, measurement of total serum IgA and IgA-antibodies against transglutaminase 2 (TGA-IgA) is superior to other combinations
  • We recommend against deamidated gliadin peptide antibodies (DGP-IgG/IgA) for initial testing
  • Only if total IgA is low/undetectable, an IgG-based test is indicated
  • If TGA-IgA is ≥10 times the upper limit of normal (10× ULN) and the family agrees, the no-biopsy diagnosis may be applied, provided endomysial antibodies (EMA-IgA) will test positive in a second blood sample. HLA DQ2-/DQ8 determination and symptoms are not obligatory criteria
  • In children with positive TGA-IgA <10× ULN at least 4 biopsies from the distal duodenum and at least 1 from the bulb should be taken

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Development of Primary Sclerosing Cholangitis in Pediatric Patients with Inflammatory Bowel Disease

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A recent study (A Chandrakumar et al. J Pediatr 2019; 215: 144-51) followed 190 children with inflammatory bowel disease from 2011 to 2018 in a longitudinal population-based cohort in Manitoba and examined the development of primary sclerosing cholangitis (PSC).  The diagnosis of PSC was made on discretion of the treating physician; thus, only a subset of patients underwent extensive evaluations for PSC.

Key findings:

  • 9 developed PSC-UC (9/95) and overall 11 developed PSC-IBD (11/190)
  • Among children with PSC-UC, 8 had high GGT (>50) at baseline and only 1 had a normal GGT at baseline.
  • All UC patients who developed PSC were diagnosed withing 6 months of their UC diagnosis.
  • At baseline, 22 patients with UC had an elevated GGT and 73 had a normal GGT.  Thus, about one-third of patients with an elevated GGT developed PSC (possibly more as all patients were not subjected to extensive testing)

My view: This study reinforces two concepts: 1) GGT is valuable as a screening test 2) PSC (often asymptomatic) is fairly common in UC and needs to be considered especially in the first year of diagnosis.  What this study does not do is help us figure out what should be done about children with asymptomatic PSC as there are no proven therapies.

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Do You Need Separate Cookware for Celiac Disease?

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Maybe.  A recent abstract at 2019 NASPGHAN meeting addressing this issue was highlighted in Gastroenterology and Endoscopy News.

Link: Recommendations for Children With Celiac Disease Need Update

An excerpt:

In two related experiments, researchers from the celiac disease program at Children’s National Medical Center in Washington D.C., looked at whether, and how much, gluten could be transferred from contaminated cafeteria foods and school supplies to children’s hands, work tables and gluten-free food (abstract 656). The researchers also analyzed how effective different washing methods were at removing gluten contamination…

Ms. Weisbrod said she and her colleagues were surprised that using a shared toaster for both gluten-free and gluten-containing bread transferred minimal gluten (<5 parts per million [ppm] in most samples), as did playing with Play-Doh (median, 1.25 ppm). Both exposures were well below the 20-ppm threshold the FDA uses to consider an item gluten-free.

My take: The NASPGHAN meeting also featured a lecture by Alessio Fasano indicating that ~30%of patients with celiac disease had persistent disease due to poor adherence with a gluten-free diet and about 10% of patients with celiac disease are exquisitely sensitive to gluten.  So, while this small study indicates that gluten exposure may be lower than gluten threshold in many cases when sharing toasters, etc, I think more attention should be directed at strict gluten avoidance rather than trying to discern if some level of cross contamination may be acceptable.

Addendum: Cross-contamination results were later published with regard to three items -cooking pasta, use of toaster, and slicing a cupcake: Gastroenterol 20202; 158: 273-5.  The associated editorial (page 51) the authors state that they do not believe that concern about gluten cross-contact is overblown and state findings should be cautiously interpreted in light of small sample size and lack of investigator blinding.

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Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

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A Little More Data on Antibiotic Cocktail for Pediatric Acute Severe Ulcerative Colitis

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A recent prospective study (D Turner et al. Inflammatory Bowel Diseases, izz298, https://doi.org/10.1093/ibd/izz298) with 28 children found improvement in 5-day PUCAI scores in patients who received quadruple antibiotics in combination with IV corticosteroids compared to those who received IV corticosteroids alone.

Link: Antibiotic Cocktail for Pediatric Acute Severe Colitis and the Microbiome: The PRASCO Randomized Controlled Trial

Methods:

Hospitalized children with ASC (pediatric ulcerative colitis activity index [PUCAI] ≥65) were randomized into 2 arms: the first received antibiotics in addition to IVCS (amoxicillin, vancomycin, metronidazole, doxycycline/ciprofloxacin [IVCS+AB]), whereas the other received only IVCS for 14 days. The primary outcome was disease activity (PUCAI) at day 5. Microbiome was analyzed using 16S rRNA gene and metagenome.My t

Results

Twenty-eight children were included: 16 in the AB + IVCS arm and 12 in the IVCS arm (mean age 13.9 ± 4.1 years and 23 [82%] with extensive colitis). The mean day-5 PUCAI was 25 ± 16.7 vs 40.4 ± 20.4, respectively (P = 0.037). Only 3 and 2 children, respectively, required colectomy during 1-year follow-up (P = 0.89). Microbiome data at time of admission were analyzed for 25 children, of whom 17 (68%) had a predominant bacterial species (>33% abundance); response was not associated with the specific species, whereas decreased microbiome

My take: Combination antibiotic therapy appears to improve disease activity in children with acute severe ulcerative colitis.  More and larger studies are needed to determine whether this is associated with improved long-term outcomes as well as which antimicrobials are optimal.

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Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Low FODMAPs Diet for Inflammatory Bowel Disease?

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A recent small study (SR Cox et al. Gastroenterology 2019: doi: 10.1053/j.gastro.2019.09.024. [Epub ahead of print]) examined the use of a low-FODMAP diet to reduce symptoms in inflammatory bowel disease.

A summary of the study in GI & Hepatology News: Low-FODMAP diet eases gut symptoms in IBD

An excerpt:

While previous research has shown that a low-FODMAP diet can relieve gut symptoms such as swelling and flatulence in people with irritable bowel syndrome, the diet has been little studied in IBD patients, for whom gut symptoms often persist even in the absence of gastrointestinal inflammation.

In a study published in Gastroenterology, Selina Cox, MD, of King’s College, London, and colleagues randomized 52 people with ulcerative colitis or Crohn’s disease with persistent gut symptoms but without active inflammation to 4 weeks on a low-FODMAP diet (n = 27) or a control diet comprising sham dietary advice (n = 25).

At 4 weeks, Dr. Cox and her colleagues reported more patients on the low-FODMAP diet reported “adequate” relief of gut symptoms (52% vs. 16%, P = .007), and saw slight improvements in health-related quality of life scores, compared with the control group. Patient-reported flatulence and bloating were significantly lower in the treatment group, while few other symptom-specific differences were seen between groups…

There were no significant between-group differences in bacterial diversity or in biomarkers of inflammation.

My take: A low-FODMAP diet may help reduce symptoms but there is no indication that this diet is an effective treatment to reduce complications or reduce inflammation for patients with Crohn’s disease or ulcerative colitis.  In addition, assistance from a dietician is recommended when implementing a low-FODMAP diet.

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AGA website for patient information: Low FODMAPs diet

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Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

 

Year in Review: My Favorite 2019 Posts

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Yesterday, I listed the posts with the most views.  The posts below were the ones I like the most.

General/General Health:

Nutrition:

Liver:

Endoscopy:

Intestinal Disorders:

 

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

 

Most Popular Posts of 2019

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The following are the most viewed posts from the past year:

Wishing friends, family and colleagues a healthy and happy New Year.

Morning in Sandy Springs, GA

 

Primary Prevention of Cow’s Milk Allergy

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A recent randomized clinical study (M Urashima et al. JAMA Pediatr. 2019;173(12):1137-1145) indicates that avoiding cow’s milk formula in the first 3 days of life may prevent the development of cow’s milk allergy. Thanks to Ben Gold for this reference.

Link to full Abstract (article behind paywall): Primary Prevention of Cow’s Milk Sensitization and Food Allergy by Avoiding Supplementation With Cow’s Milk Formula at Birth

The Atopy Induced by Breastfeeding or Cow’s Milk Formula (ABC) trial, a randomized, nonblinded clinical trial, began enrollment October 1, 2013, and completed follow-up May 31, 2018, at a single university hospital in Japan. The primary outcome was sensitization to cow’s milk (IgE level, ≥0.35 allergen units [UA]/mL) at the infant’s second birthday.

Immediately after birth, newborns were randomized (1:1 ratio) to BF with or without amino acid–based elemental formula (EF) for at least the first 3 days of life (BF/EF group) or BF supplemented with CMF (≥5 mL/d) from the first day of life to 5 months of age (BF plus CMF group).

If the mother, allocated to the BF/EF group, added more than 150 mL/d of EF to BF for 3 consecutive days, EF was switched to CMF after the fourth day. Thus, offspring allocated to BF/EF could avoid CMF for at least the first 3 days of life.

Key Finding:

  • “In this randomized clinical trial involving 312 newborns, risks of sensitization to cow’s milk and immediate-type food allergy, including cow’s milk allergy and anaphylaxis, were decreased by avoiding supplementation with cow’s milk formula for at least the first 3 days of life.”
  • “The primary outcome occurred in 24 infants (16.8%) in the BF/EF group, which was significantly fewer than the 46 infants (32.2%) in the BF plus CMF group (relative risk [RR], 0.52; 95% CI, 0.34-0.81).”
  • “The prevalence of food allergy at the second birthday was significantly lower in the BF/EF than in the BF plus CMF groups for immediate (4 [2.6%] vs 20 [13.2%]; RR, 0.20; 95% CI, 0.07-0.57) and anaphylactic (1 [0.7%] vs 13 [8.6%]; RR, 0.08; 95% CI, 0.01-0.58) types.”

This study is interesting in that it suggests that exposure to cow’s milk in the first three days of life potentially increases the risk of CMA, whereas a previous study (*see below) showed showed that early exposure to CMF within 14 days after birth reduces the risk of CMA.  In this previous study, exposure to small quantities of CMF for the first 3 days of life was not monitored. “Thus, the results of that observational study are not necessarily in contrast to those of the present trial.”

My take: This type of study is difficult to complete.  It is difficult to understand why exposure to cow’s milk in the first two weeks of life is helpful and why exposure in the first three days of life is detrimental with regard to the development of cow’s milk allergy.

*Katz Y, Rajuan N, Goldberg MR, et al. Early exposure to cow’s milk protein is protective against IgE-mediated cow’s milk protein allergy. J Allergy Clin Immunol. 2010;126(1):77-82.e1. doi:10.1016/j.jaci.2010.04.020)

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Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Briefly noted: Mortality in Acute Severe Ulcerative Colitis

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C Dong et al. AP&T 2019 https://doi.org/10.1111/apt.15592

Link: Systematic review with meta‐analysis: mortality in acute severe ulcerative colitis

Key point:

  • “Six population‐based studies with 741,743 patients and 47 referral centre‐based studies with 2556 patients were included. The pooled 3‐month and 12‐month mortalities were respectively 0.84% and 1.01%”

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