Tag Archives: celiac disease

New Serology for Celiac Disease?

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A recent study (RS Choung et al. Gastroenterol 156: 582-91) showed that synthetic neoepitopes of the transglutaminase-deamidated gliadin complex are better noninvasive biomarkers for detecting celiac disease and for monitoring mucosal healing.

Link to Graphical Abstract and Abstract: Synthetic Neoepitopes of the Transglutaminase–Deamidated Gliadin Complex as Biomarkers for Diagnosing and Monitoring Celiac Disease

The authors studied the serum samples from 90 patients with Celiac disease (CD) and from 79 healthy controls and developed a fluorescent peptide microarray platform  Then, the authors validated their findings in 82 patients with newly diagnosed CD and 217 controls.

Key findings:

  • 7% of patients with treated (with gluten free diet [GFD]) and healed CD had positive TTG-IgA and 27% of patients treated but unhealed CD mucosa had positive TTG IgA
  • With the synthetic neoepitopes, CD was identified with 99% sensitivity and 100% specificity.  The assay identified patients with CD with healed mucosa with an 84% sensitivity and 95% specificity.

My take: More precise noninvasive markers like these should help identify individuals with celiac disease and those who have responded (or not) to the recommended gluten free diet.

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Unrelated but important —NPR reports on another large study showing that MMR does not cause autism -Link: A Large Study Provides More Evidence That MMR Vaccines Don’t Cause Autism 

Related blog post: “Too many vaccines and autism” debunked

Link to full text of study from Annals of Internal Medicine: Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study

Lost Boys (& Girls) of Celiac

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The blog post alludes to the ‘lost boys of Sudan.’ Between 1987-2005, there were more than 20,000 Sudanese boys displaced by the civil wars in Sudan.

With regard to Celiac disease (CD), the problem is no where near as dire.  However, the authors of a recent abstract note poor follow-up for pediatric celiac disease and speculate that this could lead to worsened outcomes (NAPSGHAN Annual Meeting 2018; abstract 105 cited in gastroendonews.com: Clinicians Fumbling Follow-up For Celiac Kids).  Those without followup may have suboptimally-treated CD which could lead to vitamin deficiencies, and autoimmune diseases.

Key finding:

  • “We lost 25% in the first year and half within three years.”  Patients were considered lost to follow-up if they did not attend a visit with a celiac specialist for 18 months.

There has been data documenting even higher rates of poor follow-up among adults with celiac disease: Closer followup for Celiac disease & pediatric guidelines (2012)

My take: Celiac disease may have higher rates of poor follow-up than other GI conditions since symptoms may be minimal in many; however, poor followup is commonplace throughout medicine and contributes to worsened outcomes

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Highway near Death Valley

Is Deamidated Gliadin Serology a Useful Adjunct in Screening for Celiac Disease?

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A recent multicenter retrospective study (MJ Gould et al. JPGN 2019; 68: 20-5) shows that deamidated gliadin peptide (DGP) is rarely helpful in screening for celiac disease when tissue transglutaminase IgA is negative. The study identified 40 patients who had a mean age of 6.5 years at time of intestinal biopsy.

Key findings:

  • Of the 40 patients with DGP (IgG) positivity, only 1 patient (2.5%) had celiac disease; this patient was IgA deficient.
  • Among the five IgA deficient patients, only 1 with DGP positivity had celiac disease.
  • The cohort included 6 patients with DGP levels >250 U/mL (refernece <12).
  • Only 5 patients in this DGP positive cohort were younger than 2 years.  None had celiac disease

My take: This retrospective study indicates that DGP is rarely helpful in patients with negative TTG IgA results. However, this study had too few patients who were  <2 years of age and/or IgA-deficient patients to determine its utility in these groups..

Related study: AK Verma et al. JPGN 2019; 68: 26-29. This study from Italy examined oral hygiene products and determined that 62 (94%) were gluten-free (gluten level <20 ppm). Among the 4 with detectable gluten, 3 were toothpastes and 1 lipstick with values between 20.7 adn 35 ppm. My take: Oral hygiene products have very low rates of gluten contamination.

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Golden Gulch Trail, Death Valley

“If this was celiac, why didn’t it stop when she cut out gluten?”

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Here’s a link to a well-described case report. Her Searing Gut Pain Suggested Celiac Disease. Why Didn’t Cutting Out Gluten Help?

This 57 year old with ‘presumptive’ celiac disease did not improve with a gluten-free diet.  After an initial self-diagnosis and subsequently an endoscopy that also suggested celiac disease, she did not improve.  While the doctors involved in her care had labeled her ‘noncompliant,’ it turns out she did NOT have celiac disease and improved after the right diagnosis (diagnosis noted at bottom of this post).

My take: There are several entities that can mimic celiac disease (even histologically), including Crohn’s disease, Autoimmune enteropathy, CTLA4 deficiency, and Whipple’s disease (the diagnosis in this case).  When someone is not getting better, the diagnosis needs to be reconsidered.

Long-term Bone Health of Children with Celiac Disease

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In a recent study (C Canova et al. J Pediatr 2018; 198: 117-20) from Padua, Italy compared 1233 individuals with celiac disease to a comparison group of 6167 (from a population-based cohort of >200,000 individuals).  In this longitudinal study with a maximum followup of up to 23 years, the authors found no increase risk of fractures in youths diagnosed with celiac disease (HR of 0.87).

Findings:

  • 22 individuals had fractures compared to 128 in the reference population
  • Median age of celiac diagnosis was 6 years

Significance:

  • While celiac disease is linked to osteoporosis, “the vast majority of individuals with childhood celiac disease are likely to heal shortly after the introduction of a gluten-free diet.”

My take: Institution of a gluten-free diet for children with celiac disease likely removes the risk of osteoporosis.

Related blog posts:

  • Good News for Celiac Disease  –Gastroenterology 2010; 139: 763. Mortality NOT worsened in undiagnosed celiac disease (identified by review of serology) in Olmstead County, though bone density decreased. n=129 of 16,847. (?milder cases undiagnosed)
  • Common to be ‘D-ficient

Amelia Island -Restaurant Greeting

Cumberland Island 2018

Global Prevalence of Celiac Disease

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Briefly noted: P Singh et al. Clin Gastroenterol Hepatol 2018; 16: 823-36. After a systemic review which selected 96 articles from a pool of 3843 published between 1991 through 2016, the authors determined a pooled global prevalence of 1.4% in 275,818 individuals based on seroprevalence (positive TTG or EMA).  Biopsy-confirmed celiac disease was noted in 0.7% in 138,792 individuals.

In their study, biopsy-proven disease was most prevalent in Argentina, Egypt, Hungary, Finland, Sweden, New Zealand, and India.

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IBD Shorts July 2018

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DJ Gracie et al. Gastroenterol 2018; 154: 1635-46. This study of 405 adults indicated that IBD triggers anxiety and that anxiety triggers IBD. Specifically: “Baseline CD or UC disease activity were associated with an almost 6-fold increase in risk for a later abnormal anxiety score (hazard ratio [HR], 5.77; 95% CI, 1.89-17.7).  In patients with quiescent IBD at baseline, baseline abnormal anxiety scores were associated with later need for glucocorticosteroid prescription or flare of IBD activity (HR 2.08; 95% CI, 1.31-3.30).”

RL Dalal, B Shen, DA Schwartz. Inflamm Bowel Dis 2018; 24: 989-96.  This review provides updated information on epidemiology, diagnosis, and treatment recommendations for pouchitis.

A Alper et al. JPGN 2018; 66: 934-6. Key finding: Celiac disease is “not increased in children with IBD compared with non-IBD children with gastrointestinal symptoms.”  False-positive tTG serology can occur.

AK Shaikhkhalil et al. JPGN 2018; 66: 909-14. The authors showed that using a quality-improvement effort, there was increase utilization of enteral exclusive therapy (EEN).  Baseline 5.was <5% and by completion of intervention, utilization increased to approximately 50%. The interventions to achieve this are specified in this article, including talking points.  EEN is described as “nutrition therapy.” Patients are offered oral EEN and if not adequate by 3-4 days, nasogastric feedings are initiated (~15%).  Interestingly, of those to complete EEN therapy, 97% did not need NG placement.

Pictures from Ameilia Island:

Amelia Island

Eliminating Gluten Challenge for the Diagnosis of Celiac Disease

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Many patients receive a gluten-free diet (GFD) prior to a definitive diagnosis of celiac disease.  The diagnostic yield of serology can significantly decrease within a month after institution of a GFD.  A recent study (VK Sarna et al. Gastroenterol 2018; 154:886-96) has identified an HLA-DQ-Gluten Tetra

mer Blood test which can accurately identify celiac disease despite the implementation of a GFD.  This test quantifies HLA-DQ-gluten tetramer binding to T cells with flow cytometry. Key findings:

  • For patients receiving a GFD, the sensitivity was 97% and the specificity was 95% for the diagnosis of celiac disease
  • For patients not receiving a GFD, the sensitivity was 100% and the specificity was 90% for the diagnosis of celiac disease

My take: An accurate test to determine if celiac disease is present for those who have started a GFD would be quite helpful.  This HLA-DQ-Gluten Tetramer blood test still needs further validation in more patient populations. This test is NOT commerically-available at this time.

Morgan Falls

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  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.

Chattahoochee river -Morgan Falls

Does C-section Increase Risk of Celiac Disease? Probably Not

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Using data from the prospective TEDDY (The Environmental Determinants for Diabetes in the Young) from 2004-2010, a recent study (S Koletzko et al. JPGN 2018; 66: 417-24) has shown that cesarean section is not associated with an increased risk of celiac disease (CD) or celiac disease autoimmunity (CDA). TEDDY participants are at increased risk for CD and type 1 diabetes (T1D) based on HLA-risk genotypes.

Key findings:

  • Of the 6087 singletons, 1600 (26%) were born via C-section
  • C-section was associated with a lower risk for CDA (HR 0.85) and a lower risk of CD (HR 0.75)

My take: While environmental factors are likely to be responsible for increasing incidence of CD, C-section compared to vaginal delivery does not appear to be a risk factor.

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Amber Cove, Dominican Republic

Oats OK in Celiac Disease

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A recent double-blind, randomized, placebo-controlled trial (E Lionetti et al. J Pediatr 2018; 194: 116-22) examined the effect of adding oats to the diets of 79 children and compared this to a control group of 98 children; all participants had biopsy-proven celiac disease (CD).

Background:

  • “A large body of evidence has so far suggested that the consumption of pure oats is safe in the vast majority of patients with celiac disease.”
  • Still concerns persist.  In addition, the purity of oats cannot always be guaranteed.
  • Previous studies were limited by small sample sizes, short follow-up, limited details regarding oat used, and lack of detail about cross-contamination.

This study sought to remedy prior trial deficiencies and examined clinical indices,  serology, and intestinal permeability after 6, 9 and 15 months.

Key finding:

  • There were no statistically significant clinical, serologic, or intestinal permeability variables when comparing the oat group to the control group.

My take: Oats, free of cross contaminants, are safe to incorporate into a gluten-free diet for CD.

Canyon Rim

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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.