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Effect of gluten-free diet on gastrointestinal symptoms in celiac disease
Abstract
Atypical presentations of celiac disease appear to be at least as common as is the classic presentation of steatorrhea, diarrhea, and weight loss.
We examined the effect of a gluten-free diet on gastrointestinal symptoms in a cohort of US patients with celiac disease.
A follow-up survey was conducted in 215 patients who were evaluated at the University of Iowa from 1990 through 1997 as having biopsy-confirmed celiac disease. The systematic survey asked detailed questions regarding gastrointestinal symptoms before and after the institution of a gluten-free diet in the patients, all of whom had been given the same dietary advice.
The group consisted of 160 female and 55 male patients. Although diarrhea was the most frequent symptom in untreated celiac disease, steatorrhea occurred in only one-fifth of patients. Other complaints were common, and most responded to gluten exclusion. The benefit of gluten exclusion was equally apparent in men and women. Diarrhea responded in most patients, usually within days, and the mean time to resolution was 4 wk. Many patients had alternating diarrhea and constipation, both of which were responsive to the gluten-free diet. Most patients had abdominal pain and bloating, which resolved with the diet.
Celiac disease causes a wide range of gastrointestinal symptoms. Clinicians must have a high level of suspicion to detect the atypical forms of celiac disease. With a gluten-free diet, patients have substantial and rapid improvement of symptoms, including symptoms other than the typical ones of diarrhea, steatorrhea, and weight loss.
... [44][45][46] Celiac disease in its classic form presents with gastrointestinal malabsorption symptoms, but we need to be careful in diagnosing as about 40% of patients with CD are obese at diagnosis and constipation can be presenting symptom in 20% of patients. 15,16,47,48 Another rare presentation is the celiac crisis which presents as diarrhea and shows severe electrolyte disturbances. 48 In the past, majority of diagnosed cases were of symptomatic disease but now the non-classic and subclinical forms are increasingly diagnosed but the classic form is still the most common presenting type and makes about half of the diagnosed cases. ...
... 46,98,99 Strict adherence to gluten-free diet results in resolution of symptoms within days to weeks, negative serology, and normalization of villous atrophy. 47,100 Although a gluten-free diet is very effective in treating CD, still it comes with many disadvantages, including high cost, nutrient and mineral deficiencies, psychological impact, constipation, and cardiovascular disease risk. [100][101][102][103] To avoid these negative effects of a gluten-free diet, it is recommended to have a regular follow-up with a trained dietitian who carries expertise in treating patients with CD. 104,105 One main reason for non-adherence to a gluten-free diet is wrong online information about gluten products, cross-contamination, presence of a small amount of gluten in medications, social pressure in adolescence, and for all these reasons close follow-up with dietitian and enrollment in a CD support group is recommended. ...
... In serological testing, there is a noticeable decrease in antibody titers after 6 months, so the first follow-up is advised to be scheduled after 6 months of the diagnosis, followed by every 12 to 24 months. 47,129 The histological changes take more time to correct, so it is advisable to repeat biopsy after 1 year of treatment and even better if done after 2 years to confirm complete healing. 130 Celiac disease is associated with conditions like autoimmune thyroid disease, type 1 diabetes, inflammatory bowel disease, autoimmune hepatitis, autoimmune gastritis, primary biliary sclerosis, and adrenal insufficiency, so physicians need to be vigilant and keep a close eye on these conditions and check anti-nuclear and other organ-specific antibodies during follow-up visits. ...
Celiac disease (CD) is an autoimmune disorder that affects genetically predisposed individuals who are sensitive to gluten and related proteins. It affects children and adults with increasing prevalence in the older age groups. Both adaptive and innate immune responses play role in CD pathogenesis which results in damage of lamina propria and deposition of intraepithelial lymphocytes. There are other proposed mechanisms of CD pathogenesis like gastrointestinal infections, intestinal microbiota, and early introduction of gluten. The diagnosis of CD is based on clinical symptoms and serological testing, though a majority of cases are asymptomatic, and small intestinal biopsies are required to confirm the diagnosis. Celiac disease is generally associated with other autoimmune diseases, and it is advisable to test these patients for diseases like type 1 diabetes mellitus, Addison’s disease, thyroid diseases, inflammatory bowel disease, and autoimmune hepatitis. The patient with a new diagnosis of CD requires close follow-up after starting treatment to see symptom improvement and check dietary compliance. A newly diagnosed patient is advised to follow with a dietitian to better understand the dietary restrictions as about 20% of patients stay symptomatic even after starting treatment due to noncompliance or poor understanding of diet restrictions. The most effective treatment for CD is a gluten-free diet, but work on non-dietary therapy is in process and few medications are in the clinical trial phase.
... 63 In the last few years, some hypotheses have been advanced to explain the coexistence between CD and overweight/obesity (Fig. 2). 60,64,65 One of the most debated explanations is related to the ability of the small intestine, the target organ of CD, to adapt to the surrounding stressful environment. 66 Thus, the ''compensatory hypothesis'' 64 describes how the plasticity of the intestinal epithelium plays an important role in response to trauma, carrying out morphological and functional changes also in subjects with CD, where the distal part of the small intestine (ileum) strengthens its absorption properties as the duodenum and jejunum are atrophic. ...
... 64 However, the extent of intestinal damage defines the severity and type of clinical manifestations, 12,67 also influencing the patient's BMI. 17 Another possible explanation for the coexistence between CD and overweight/obesity is that micronutrient deficiencies, due to malabsorption, can cause specific food cravings in adults, leading to increased BMI. 65 This probably also occurs in children and adolescents with CD, bearing in mind that the food craving is often for processed, junk, or high-calorie food 68 and that these patients usually consume lower amounts of fruits and vegetables, as recently shown by Calcaterra et al. 30 As previously mentioned, on one hand, school-age children and adolescents are more autonomous and influenced by their peers and social media marketing concerning food choices resulting in a shift toward unhealthy dietary patterns 61,62 ; this can lead to the consumption of high-caloric and processed food that, together with reduced physical activity, leads to excessive weight gain. 63 On the other hand, an unbalanced diet rich in fat and sugar changes the composition of the gut microbiota, causing dysbiosis, which is defined as perturbations to the structure of complex commensal communities because an imbalance between increased pathogenic microbes and reduced beneficial bacteria occurs. ...
Background: Celiac disease (CD) is a multifactorial, immune-mediated enteropathic disorder that may occur at any age with heterogeneous clinical presentation. In the last years, unusual manifestations have become very frequent, and currently, it is not so uncommon to diagnose CD in subjects with overweight or obesity, especially in adults; however, little is known in the pediatric population. This systematic review aims to evaluate the literature regarding the association between CD and overweight/obesity in school-age children. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. An electronic database search of articles published in the last 20 years in English was carried out in Web of Sciences, PubMed, and Medline. The quality of the included studies was assessed by using the STrengthening the Reporting of OBservational studies in Epidemiology statement. Results: Of the 1396 articles identified, 9 articles, investigating overweight/obesity in children/adolescents affected by CD or screening CD in children/adolescents with overweight/obesity, met the inclusion criteria. Overall, the results showed that the prevalence of overweight or obesity in school-age children (6-17 years) affected by CD ranged between 3.5% and 20%, highlighting that the coexistence of CD with overweight/obesity in children is not uncommon as previously thought. Conclusion: Although CD has been historically correlated with being underweight due to malabsorption, it should be evaluated also in children with overweight and obesity, especially those who have a familiar predisposition to other autoimmune diseases and/or manifest unusual symptoms of CD.
... Coeliac disease (CD) is an immune-mediated enteropathy triggered by gluten ingestion in genetically predisposed subjects [4]. The start of the gluten-free diet (GFD) is the only known treatment able to ameliorate gastrointestinal symptoms and/or malabsorptive signs and restore duodenal mucosal atrophy in a heterogeneous range of CD patients [4,5]. Factors influencing adherence to GFD are widely studied [6]. ...
... Regarding the presence of GI symptoms after GFD, we reported a significant improvement of symptoms during the follow-up, with no significant differences regarding symptoms prevalence between males and females. This is in line with the positive effect of GFD [5] that, in our cohort, seems to occur after a few months regardless of the prevalence of upper and lower GI symptoms and the gender of the patients. We can speculate that females, having more symptoms at diagnosis compared to males, showed a greater clinical improvement. ...
Coeliac disease (CD) is an immune-mediated enteropathy triggered by gluten ingestion. At CD diagnosis, gender differences have been previously reported, but data regarding follow-up are scant. We investigated gender differences in CD adult patients both at the time of diagnosis and at follow-up after the start of the gluten-free diet (GFD). This is a longitudinal cohort study on adult CD patients diagnosed between 2008 and 2019. Clinical, biochemical, and histological data were assessed and compared between males and females. At diagnosis, female gender was significantly associated with signs of malabsorption (OR 3.39; 95% CI: 1.4–7.9), longer duration of symptoms and/or signs before the diagnosis (OR 3.39; 95% CI: 1.5–7.5), heartburn (OR 2.99; 95% CI: 1.1–8.0), dyspepsia (OR 2.70; 95% CI: 1.1–6.5), nausea/vomit (OR 3.53; 95% CI: 1.1–10.9), and constipation (OR 4.84; 95% CI: 1.2–19.6) and less frequently associated to higher body mass index (OR 0.88; 95% CI: 0.8–0.9) and osteopenia/osteoporosis (OR 0.30; 95% CI: 0.1–0.7) compared to male patients. After 12–30 months, females presented lower median BMI, performed less frequently histological control, and had more frequently anaemia and hypoferritinaemia compared to males. No significant differences concerning the presence of gastrointestinal symptoms, adherence to GFD, and Marsh score were found. Gender differences found at CD diagnosis mostly disappear at the follow-up, showing that these differences can be solved over time.
... However, the data used to support such claims are often questionable. For example, data from a clinical study that showed that eliminating gluten consumption from the diet resulted in weight loss (in 25 coeliac patients) (Murray et al., 2004) was used as evidence that gluten ingestion resulted in weight gain (Davis, 2012). However, the study that was referred to (Murray et al., 2004) also noted that 91 patients gained weight after gluten exclusion, which was ignored. ...
... For example, data from a clinical study that showed that eliminating gluten consumption from the diet resulted in weight loss (in 25 coeliac patients) (Murray et al., 2004) was used as evidence that gluten ingestion resulted in weight gain (Davis, 2012). However, the study that was referred to (Murray et al., 2004) also noted that 91 patients gained weight after gluten exclusion, which was ignored. Miller Jones (Miller-Jones, 2012) has challenged many such claims and many questions remain unanswered. ...
Observations from animal and in vitro laboratory research, and anecdotal evidence, have led to the suggestion that gluten consumption stimulates weight gain by the presence of peptides expressing opioid activity. Another proposed mechanism is that gluten peptides decrease resting energy expenditure resulting in a positive energy balance. In order to induce such effects in vivo, intact food peptides must be absorbed in sufficient quantities, remain intact in the blood for sufficient time to have long‐lasting biological activity and bind to receptors involved in appetite, satiety and energy regulation. However, although peptides from food may pass from the intestine into the blood in extremely low quantities, they are generally rapidly degraded by plasma and vasculum‐bound aminopeptidases, resulting in very short half‐lives and loss of bioactivity. At present, gluten peptide sequences that influence regulators of energy metabolism have not been identified. Furthermore, data on the quantitative absorption of gluten peptides in the blood stream, their stability and lasting bioactivity are also lacking. Therefore, there is no evidence for proposed effects on driving appetite by the brain, nor on energy expenditure and weight gain. Furthermore, the level of overweight observed in various countries appears to be independent of the level of wheat consumption, and abundant observational evidence in humans shows that the levels of gluten consumption are neither related to daily calorie intake nor to BMI. This narrative review therefore discusses the proposed effects of gluten on bodyweight (BW) and putative biological mechanisms in the light of the current evidence.
... Celiac disease, otherwise known as gluten-sensitive enteropathy, treats with a strict lifelong adhesion to a gluten-free diet (Murray et al., 2004;Alvarez-Jubete et al., 2009;Göncü & Çelik, 2020). With a gluten-free diet, patients have substantial and rapid improvement of symptoms, including symptoms other than the typical ones of diarrhea, steatorrhea, and weight loss (Murray et al., 2004). ...
... Celiac disease, otherwise known as gluten-sensitive enteropathy, treats with a strict lifelong adhesion to a gluten-free diet (Murray et al., 2004;Alvarez-Jubete et al., 2009;Göncü & Çelik, 2020). With a gluten-free diet, patients have substantial and rapid improvement of symptoms, including symptoms other than the typical ones of diarrhea, steatorrhea, and weight loss (Murray et al., 2004). It is very difficult for celiac patients to find "safe" meal outside home. ...
Abstract In this study, potato flour used in gluten free cracker formulation was substituded with pseudocereal (amaranth, buckwheat, quinoa) flours, and the effects of pseudocereals on some chemical, physical and sensory characteristics of gluten-free crackers were determined. Results show that the crackers having pseudocereals had significantly higher (p < 0.05) fat, protein, insoluble and total dietary fiber, essential and non essential amino acid, and Mg contents than control sample which was produced with potato flour and potato starch. In addition, crackers having amaranth had higher (p < 0.05) Ca and P contents than control. Pseudocereal containing crackers had lower L* and higher a* values than control, and according to ΔE values, they were evaluated as extreme (another) color group than control crackers. In SEM micrographs, more cracks and pores were observed with the addition of pseudocereal flours to crackers. Therefore, hardness decreased significantly with pseudocereal flours addition in crackers. Flavor, chewiness, crispiness and overall acceptability scores of crackers having pseudocereal flours were higher than control in sensory analysis.
... 10 11 Symptoms can improve within days to weeks on a GFD. 12 Once diagnosed and treatment is started, QoL improves 10 13-15 but may not normalise. 16 The diet is restrictive, and it can be difficult for people to adjust to. ...
Objective
Patients with coeliac disease (CD) need to follow a strict gluten-free diet to manage symptoms and prevent complications. Restrictions imposed by the diet can be challenging and affect quality of life (QoL). We explored sources of variation in QoL among patients with CD.
Design
We conducted an online survey of coeliac patients in the UK, including a CD-specific QoL tool (CD-QOL V.1.0), questions on diet adherence and an optional comment box at the end. The survey was disseminated via social media and went live between January and March 2021. We performed multiple linear regression and free text analysis.
Results
We found a median CD-QOL score of 61 (IQR 44–76, range 4–100, n=215) suggesting good QoL (Good >59); however, the individual QoL scores varied significantly. Regression analyses showed that people who found diet adherence difficult and people adhering very strictly had a lower QoL. Free text comments suggested that people who adhered very strictly may do so because they have symptoms with minimal gluten exposure. People who found diet adherence difficult may be people who only recently started the diet and were still adjusting to its impact. Comments also highlighted that individuals with CD often perceive a lack of adequate follow-up care and support after diagnosis.
Conclusion
Better support and follow-up care is needed for people with CD to help them adjust to a gluten-free diet and minimise the impact on their QoL. Better education and increased awareness are needed among food businesses regarding cross-contamination to reduce anxiety and accidental gluten exposure.
... No drug therapy is better than GFD in CD, and the current evidence does not support any adjunctive therapy [16]. In the majority of cases, strict adherence to GFD leads to the disappearance of clinical symptoms, serological signs, and histology alterations in the duodenum and the prevention of complications of CD [17]. ...
Background: The main treatment for Celiac Disease (CD) is the gluten-free diet (GFD). However, in some CD patients, iron deficiency anemia can be persistent despite a GFD.
Aim: In this study, we aim to evaluate the prevalence of anemia in both adult and pediatric CD patients at the diagnosis and during the GFD.
Methods: In this cross-sectional study including both adult and pediatric CD patients, the demographic characteristics and hemoglobin, iron, folate and vitamin B12 levels were retrospectively retrieved from patients’ medical records at the time of diagnosis (T0); after 3-5 years (T1) and after 8-10 years (T2) of GFD.
Results: 311 CD patients (184 adult and 127 pediatric patients) were included in the study. No difference was observed in the prevalence of anemia in the overall population after 3-5 years of GFD in both adult and pediatric patients compared to the diagnosis. At T2, in the adult patient’s group, only a slight reduction in the prevalence of anemia was observed (24% vs 17.8% p=0.043).
Conclusions: Despite the GFD and a very long observational period the diagnosis of anemia persists in 17.8% and 4.4% of adult and pediatric patients, respectively. The diagnostic delay (longer in adult patients) and a more pronounced ultrastructural mucosal injury could play a role in the persistence of anemia despite the GFD.
... The signs and symptoms of CD are varied. The classic ones include diarrhoea, bloating, and weight loss, and nausea or flatulence may also occur [10]. Extra-gastrointestinal symptoms, such as iron-deficiency anaemia [11], dermatitis herpetiformis [12], or thrombotic events [13], may also occur, and an asymptomatic development of the disease is possible [14,15]. ...
... Symptoms improve within days of GFD onset and precede histologic results (5). Diseasespecific antibody levels tend to become normal within a few months of GFD onset. ...
Unlabelled:
Study background and objectives: There is great disparity in mucosal recovery among celiac patients on a gluten-free diet. We report a study to identify associated factors.
Methods:
Celiac patient cases were collected that had positive celiac serology and villous atrophy at diagnosis, and had undergone a control biopsy after at least 12 months of follow-up.
Results:
We included 70 celiac patients. They had experienced symptoms for 9.05 ± 9.48 years before being diagnosed. After follow-up for 2.93 ± 1.94 years, 34.3 % had complete mucosal recovery and 57.1 % had partial mucosal recovery. In the comparative analysis we found no relationship between mucosal recovery and sex, age, clinical manifestations or follow-up time from diagnosis to second biopsy. Time with clinical manifestations before diagnosis was associated with a worse outcome: 2.64 years in patients with full recovery, 4.61 years in patients with partial recovery, and 14.26 years in patients with persistent villous atrophy. Higher transglutaminase antibody titers both at diagnosis and during follow-up were associated with poorer histologic outcomes. We observed higher mucosal recovey rates in patients with mild atrophy versus severe atrophy at diagnosis.
Conclusions:
In spite of gluten-free diet a significant proportion of patients have persistent histologic changes. Time with clinical manifestations before diagnosis is key for histological severity and recovery.
... Gluten exposure leads to damage of the small bowel mucosa characterized by intraepithelial lymphocytosis, crypt hypertrophy, and varying degrees of villous atrophy. Withdrawal of gluten reverses the pathological changes, but diarrhea may persist in up to 30% of individuals despite adherence to the diet [41]. In some patients this may be due to co-existing microscopic colitis [42]. ...
Purpose of review
Irritable bowel syndrome with diarrhea (IBS-D) is diagnosed when chronic symptoms of abdominal pain accompany loose stools, and alarm features, such as fever, anemia, rectal bleeding, and weight loss are absent. This combination of symptoms makes structural disorders, such as inflammatory bowel disease or cancer, unlikely, but does not exclude other conditions that cause these symptoms. The question is whether making a “positive diagnosis” of IBS-D based on symptoms alone and instituting therapy based on that diagnosis still makes sense.
Recent findings
Clinical observations suggest that at least two-thirds of cases of IBS-D can be explained by three mechanisms: a) food intolerances (~ 30—40%), b) bile acid diarrhea (~ 20—30%), and c) disturbed microbial flora (~ 15—20%). Other conditions that are less frequent but can cause IBS symptoms or be confused with IBS include: celiac disease, microscopic colitis, mastocytosis/mast cell activation, and drug side-effects.
Summary
Many cases of IBS-D have a discoverable, underlying cause that can direct therapy more efficiently.
... Gluten-free diet requires strong commitment by patients and their families as well as adequate instructions/follow-up by trained staff (physicians, dieticians, and psychologists) to ensure avoidance of hidden gluten sources, to suggest healthy nutritional choices and to support possible psychological burden of the dietary restriction. This explains why early diagnosis and subsequent follow-up are of utmost importance [9]. ...
Background: Strategies for diagnosing celiac disease (CD) include case-finding and population-screening programs. Case finding consists of testing individuals at increased risk for the disease due to symptoms or associated conditions. Screening programs are widespread campaigns, which definitely perform better in terms of unveiling CD diagnoses but nowadays are still debatable. The global prevalence of CD is around 1% but it almost doubles when considering screening programs among school children. Within this framework, we aimed to estimate the prevalence of CD among hospitalized children in the Pediatric Department of a Southern Italy University Hospital in the period from January 2018 through December 2021. In addition, we attempted to explore, at the time of diagnosis, the prevalence of leading clinical alerts due to malabsorption/malnutrition such as anemia or failure to thrive or due to systemic inflammation/immune dysfunction as hypertransami-nasemia and thyroid dysfunction. Methods: Data records of pediatric patients admitted as inpatients and tested by anti-transglutaminase IgA antibodies (TGA-IgA) were retrospectively analyzed. CD was diagnosed according to either 2012 or 2020 ESPGHAN guidelines, depending on the year of diagnosis. CD autoimmunity (CDA) was a wider group defined within our protocol if patients had elevated TGA-IgA on at least one occasion, regardless of anti-endomysial antibodies (EMA-IgA) and without biopsy confirmation. Results: During the observation period, 3608 pediatric patients were admitted and 1320 were screened for CD (median age 5 years, IQR 2-9 years; CD test rate: 36.6% out of all admissions). The available prevalence of newly diagnosed CD was 1.59% (21 patients diagnosed) and the available prevalence of CDA was 3.86% (51 subjects). Among CD patients, underweight/malnourished children accounted for 28.6% (6 out of 21). Conclusions: The estimated prevalence of CD diagnoses within our setting was comparable to the most recent population-screening programs. The estimated prevalence of CDA was even higher. A hospital-admission CD testing during routine blood draws might be a non-invasive, cost-effective and valuable approach to reduce discrepancy of prevalence between case-finding and population-screening programs.
... 9 One cohort study reported that one-third of newly treated patients gain weight after going gluten-free for 6 months. 10 A case-control study reported that over one-third of patients with CeD compliant with GFD had nonalcoholic fatty liver disease. 11 Also, previous reports have suggested that patients with CeD have a higher risk of adverse cardiovascular outcomes. ...
Goals
We aim to describe the weight loss outcomes of patients with celiac disease (CeD) taking antiobesity medications (AOMs) and compare it with the weight loss outcomes of patients without CeD taking AOMs.
Background
Increasing rates of obesity and obesity-associated comorbidities have been previously reported in patients with CeD on a gluten-free diet. The effectiveness of AOMs in this population has not been previously described.
Methods
In our retrospective cohort study, we matched 39 patients with treated CeD to 78 patients without CeD based on sex and AOM. We assessed the weight loss outcomes at 3, 6, and 12 months after starting the AOM in both cohorts and analyzed if there was a differential response when comparing by type of AOM [injectable glucagon-like peptide 1 (GLP-1) receptor agonists vs. oral non-GLP-1 AOMs].
Results
Both cohorts had similar baseline demographic and anthropometric characteristics. At 12 months, the CeD cohort had a nonsignificantly inferior total body weight loss percentage compared with the cohort without CeD (6.5% vs. 9.5%, P =0.13). The CeD cohort had a similar proportion of patients achieving a total body weight loss percentage of ≥5% than the cohort without CeD (72.7% vs. 72.1%, P =1.00). No significant difference was observed when comparing the weight loss outcomes of injectables (GLP-1 receptor agonists) to oral AOMs. The proportion of patients reporting side effects was similar for both groups, regardless of the type of AOM.
Conclusion
Patients with CeD taking AOMs had similar weight loss outcomes to patients without CeD. Hence, AOMs can be a safe and effective therapy for weight management in patients with CeD.
... Other complaints were prevalent and mostly responded to the GFD. The efficacy of GFD was observed to be equal in both genders (25). ...
Background: Celiac disease (CD) treatment is based on life-long adherence to a gluten-free diet (GFD). Some patients with CD experience persistent symptoms despite adhering to a GFD. This condition is defined as a nonresponsive CD. Objectives: The present study aimed to investigate the prevalence and cause of persistent symptoms in pediatric patients with CD adhering to a GFD in Sistan and Baluchestan province, southeastern Iran. Methods: This descriptive cross-sectional study was conducted on 112 patients with CD selected from all diagnosed CD patients receiving a GFD for 6 months and newly diagnosed cases studied within one year. Gastrointestinal (GI) and extraintestinal (EI) symptoms were recorded on a questionnaire at the onset and during treatment. Data were analyzed by SPSS16 software, independent t-test, univariate t-test, and analysis of variance (ANOVA). Results: A total of 46.43% of our sample were boys, and 53.57% were girls (mean age = 82 ± 4.43 months). Abdominal pain and constipation symptoms were reported more frequently at the time of diagnosis and following one year of treatment. The most commonly observed EI symptoms at the time of diagnosis and during treatment were weight loss and growth failure, respectively. The percentage of treatment non-response in patients with a positive family history was significantly greater than in those with a negative family history. Conclusions: The results showed that GFD had a significant effect on the reduction of GI and non-GI symptoms, but the effect of this regime on insignificant symptoms, particularly at older ages, is negligible.
... The signs and symptoms of CD are varied. The classic ones include diarrhoea, bloating, and weight loss, and nausea or flatulence may also occur [10]. Extra-gastrointestinal symptoms, such as iron-deficiency anaemia [11], dermatitis herpetiformis [12], or thrombotic events [13], may also occur, and an asymptomatic development of the disease is possible [14,15]. ...
Unlabelled:
The assessment of the nutritional and inflammatory status of paediatric patients with coeliac disease is an interesting approach to early diagnosis and functional follow-up. Most authors agree that the normalisation of symptoms takes about one year. The aim of the study was to evaluate the clinical manifestation and normalisation of routine analytics in Spanish children diagnosed with celiac disease.
Methods:
We performed a retrospective case-control study in Spanish paediatric patients, including 21 celiac patients and 20 healthy controls. The 21 patients selected in the case-control study were followed for 5 years after starting a gluten-free diet (GFD). All patients had type 3 villous atrophy according to the Marsh-Oberhuber classification. A total of 39 blood samples were taken before the start of the GFD, and 109 were taken after. Twenty control sera from healthy donors were used for comparison.
Results:
We found that patients had a subclinical but statistically significant increase in blood calcium, transaminases, and white blood cells, and a decrease in serum iron, at the time of diagnosis. Our study also shows that analytical values normalise within five years on a gluten-free diet.
Conclusions:
The use of a combination of subclinical changes, including low iron, high calcium, elevated leukocytes, lymphocytes, and ALT levels in blood samples, together with a low growth percentile, is pertinent in detecting coeliac disease. This set of parameters could help in the diagnosis of patients without clinical symptoms. We can also show that the levels of Fe, Ca, transaminases, and leucocytes remain subclinically altered after 3 years, despite the gluten-free diet.
... Whilst the only effective treatment for CD is a GFD, which can lead to symptom improvement within days to weeks [15,16], there is much less known about the duration and need for adherence to a GFD in patients with NCGWS [1]. It has been shown that patients with NCGWS do see an improvement in their symptoms following the elimination of gluten and/or wheat from their diets. ...
Introduction:
The role of a gluten-free diet (GFD) in Non-Coeliac Gluten/Wheat Sensitivity (NCGWS) is unclear. We present the largest study comparing adherence to a GFD in patients with Coeliac Disease (CD) and NCGWS and assess its impact on quality of life (QoL) and sleep in patients with NCGWS.
Methods:
Patients with NCGWS at a tertiary centre completed the Coeliac Disease Adherence Test (CDAT), Coeliac Symptom Index (CSI) and Sleep Condition Indicator (SCI). Higher CDAT scores indicate worse adherence, higher CSI scores indicate poorer QoL, and higher SCI scores indicate better sleep. CDAT scores were correlated with CSI and SCI scores. A second group of patients with CD completed the CDAT questionnaire only. Results were compared with the CDAT responses from the NCGWS group.
Results:
For the NCGWS cohort (n = 125), the median CDAT score was 17/35, indicating poor adherence. The median CSI score was 44/80, with 40% of scores associated with a poor QoL. The median SCI score was 14/32, and DSM-V criteria for insomnia was met by 42% of patients. There was a positive correlation between CSI and CDAT scores (r = 0.59, p < 0.0001) and a negative correlation between SCI and CDAT scores (r = -0.37, p = 0.0002). In the CD cohort (n = 170), the median CDAT score was 13/35. Patients with NCGWS had poorer adherence compared to CD (CDAT: 17.0 vs. 13.0, respectively, p = 0.0001).
Conclusion:
Patients with NCGWS adhere to a GFD less than those with CD. Poorer adherence to a GFD in patients with NCGWS correlates with a worse QoL and sleep performance.
... Nowadays, the mainstay treatment for CeD remains a strict gluten-free diet [GFD] that permits intestinal damage recovery, proper absorption of nutrients, and symptom resolution in most cases [9,10]. ...
The gluten-free diet [GFD] has been linked to an increased risk of weight gain and the development of metabolic disorders. Most of the studies have focused on the effect of GFD on the Body Mass Index [BMI]. We aimed to evaluate the nutritional status using specific nutritional parameters in patients with celiac disease [CeD] at diagnosis and on a GFD compared to healthy controls. We recruited subjects at our outpatient clinic at the University of Padua. We collected demographic and clinical data and values obtained with bioelectrical impedance analysis. A total of 24 CeD patients and 28 healthy controls were enrolled. CeD patients at diagnosis had a lower body cell mass index [BCMI, p = 0.006], fat-free mass index [FFMI, p = 0.02], appendicular skeletal muscle index [ASMI, p = 0.02], and phase angle [PA] [p < 0.001] compared to controls. Their percentage of extracellular water [ECW] was also higher [p < 0.001]. Considering CeD patients after GFD, nutritional status significantly improved after 6 months of GFD. We did not observe differences in BMI among groups [p = ns]. CeD patients at diagnosis were found to have a poorer nutritional status than healthy controls, with a positive effect of the GFD on their nutritional status, underlining the inefficacy of evaluating this aspect through only BMI evaluation.
... 4 Currently, the treatment of CD is limited exclusively to lifestyle modification by adhering to a gluten-free diet, which often improves symptoms within a short time and precedes normalization of serological markers and of duodenal villous atrophy. 5 However, despite being an effective treatment, a gluten-free diet has numerous difficulties. Gluten-free products are usually more expensive compared with their gluten-containing counterparts, which poses an economic burden on patients. ...
Introduction:
Previous studies have indicated that patients with celiac disease (CD) may have an increased risk of developing neuropsychiatric disorders. However, large-scale epidemiologic studies on the topic are still scarce. We aimed to examine the association between CD and development of neuropsychiatric disorders during an 18-year follow-up period.
Methods:
We conducted a prospective cohort study. All Danish patients with an incident diagnosis of CD (ICD-10 K90.0) from 2000 to 2018 were identified in nationwide registries and compared with birthdate- and sex-matched controls (variable 1:10 ratio) for the development of a neuropsychiatric disease. Individual neuropsychiatric diseases were also examined. The absolute risk was calculated by the cumulative incidence, and the relative risk was estimated in Cox regression models.
Results:
We identified a cohort of 6329 patients with CD diagnosed from 2000 to 2018 and 63,287 matches at risk for developing incident neuropsychiatric disorders. The cumulative incidence of development of any neuropsychiatric disorder was 3.9%, 14.9%, 24.8%, 35.9% after 1, 5, 10, and 15 years of follow-up, respectively, in patients with CD compared with 1.8%, 9.3%, 18.3%, and 27.0% in controls. Gray's test for equality p < 0.001. The relative risk was HR = 1.58 (95% confidence interval: 1.49-1.68) in CD patients compared with matches. For the individual outcomes, CD was associated with an increased relative risk of developing anxiety, depression, eating disorders, epilepsy, migraine, and stress. We also found indications of an increased relative risk of ADHD, alcoholism, bipolar disorders, and drug abuse, although the associations were less clear. No associations were found between CD and dementia, Parkinson's disease, and schizophrenia.
Conclusions:
In this nationwide study including more than 6000 patients with CD, we found an increased risk of development of a neuropsychiatric disorder compared with age- and sex-matched controls. The causes and the clinical relevance of these associations remain to be elucidated.
... Nowadays, the motivation for improving and developing gluten-free foods have attracted much research interest (Rosell et al., 2014). Especially with rising number of patients with gluten sensitivity and celiac disease (Lebwohl et al., 2015), in addition to the rapid change in consumer lifestyle, where gluten-free diet is also associated with weight management and overall health (Lamacchia et al., 2014;Murray et al., 2015). ...
... Patients may present with a variety of symptoms including abdominal pain, diarrhea, steatorrhea, fatigue, weight loss and bloating. [3] Diagnostic evaluation for CD patients includes screen with serology testing for IgA anti-tTG antibodies, IgG anti-tTG antibodies with serum IgA levels (if a patient is suspected to be IgA deficient) and confirmation with duodenal biopsy with histological analysis, which is the gold standard test for CD diagnosis. To confirm a diagnosis of CD, patients must be on a normal diet prior to serology testing. ...
Background
Celiac disease (CD) is caused by an immune response to gluten and treatment is adherence to a gluten-free diet. Guidelines from studies in large academic settings recommend registered dietitian (RD) referrals at time of diagnosis and periodic testing for micronutrient deficiencies. There is limited data to guide follow-up parameters in a large, community-based practice. The purpose of this study was to evaluate guideline adherence in this setting.
Methods
This retrospective study conducted in 2019 assessed CD care based on follow-up rates, micronutrient testing, symptoms, and serology results in cohorts with and without RD referrals. Patients in this study were followed at Rockford Gastroenterology Associates (RGA): a large, private GI practice. Patients were included if they had a diagnosis of CD from 1/2014 through 12/2018, based on positive serology and/or duodenal biopsy. Patient data was collected by chart review and analyzed through Microsoft Excel. Fisher’s exact and Chi-square tests were used for the statistical analysis and were calculated through the Statistical Product and Service Solutions (SPSS) software.
Results
320 patients were initially reviewed and a cohort of 126 patients met inclusion criteria. 69.8% had a RD referral. 65.9% had at least one lab test order for any of the 6 micronutrients. Of 63 patients tested for iron, 11 were iron deficient (8 with RD referral). Of 64 patients tested for vitamin D, 21 were deficient (17 with referral). 80.2% attended at least one follow-up appointment, but 34.9% had only one follow-up visit over a mean follow up duration of 5.82 months. 79 patients had follow-up data for symptoms or serology and were separated into 4 categories (with vs. without RD referral): (1) asymptomatic and negative serology (32% vs. 26%), (2) symptomatic and negative serology (28% vs. 16%), (3) asymptomatic and positive serology (27% vs. 32%), (4) symptomatic and positive serology (13% vs. 26%). Category 1 yielded a fisher exact test value of 2.62 (p = 0.466).
Conclusions
RD referral, micronutrient testing, and close follow-up are important parameters that affect outcomes in patients with CD. Rates for dietitian referral, some micronutrient testing and follow-up visits were higher than 50%, though results from this study were not statistically significant. Further standardization of follow-up testing and monitoring for CD will help minimize discrepancies between community-based and large, academic GI practices.
... Our study demonstrated a reduction in symptoms and antibody levels after GFD introduction, consistent with previous literature. [21][22][23] Normalization of antibody levels was not present in all patients. GFD compliance is a principal factor in determining the rate of seroconversion. ...
Purpose Celiac disease (CD) is a disorder in which gluten ingestion triggers an autoimmune response causing inflammation and damage to the small intestine. With improved awareness and screening availability, prevalence and variation in clinical presentation have subsequently increased. Thus, our study identified the disease characteristics and presentation patterns of pediatric CD in southern West Virginia. Methods We retrospectively reviewed charts for pediatric patients (age <18 years) diagnosed with CD during a 10-year period at a tertiary care hospital. Results A total of 59 patients met inclusion criteria. The mean age of diagnosis was 10.0+4.6 years, with 61% of patients being female. One-third of cases were asymptomatic and diagnosed from screenings of patients with hypothyroidism or type 1 diabetes mellitus. In symptomatic patients (n=40), abdominal pain was the most common presenting symptoms (78%), followed by constipation (30%). Classical symptoms of diarrhea and failure to thrive/unexplained weight loss were less common (n=9). At diagnosis, anti-tissue transglutaminase (tTG) IgA antibodies and deamidated gliadin peptide IgG antibodies were both positive in 88% of cases, and endomysial antibodies were positive in 70% cases. One-year post-diagnosis clinic follow-up rate was 63%. A gluten-free diet improved symptoms and tTG IgA serology levels in all patients with follow-up. Conclusion Our data fills in the gap of the paucity of information available about CD in children from Appalachia. A high index of suspicion is required to screen and diagnose CD as many patients are either asymptomatic or lack classical findings. A gluten-free diet is a highly effective treatment, although follow-up after initial diagnosis remains a challenge.
... In recent decades, the incidence of CD has significantly increased in industrialized countries [3], and currently, a strict gluten-free diet (GFD) is the only effective treatment for CD. Adherence to a GFD usually reduces the symptoms and intestinal damage [4]. However, the chronicity of this disease and the difficulties associated with having a permanently restrictive diet can affect the quality of life of CD patients and their families [5,6]. ...
Maintaining a strict gluten-free diet (GFD) may affect the quality of life of children with celiac disease (CD) and promote a less healthy diet by substituting gluten-containing foods with ultra-processed foods. We aimed to assess the influences of the GFD and ultra-processed food consumption on parents’ perception of the quality of life of children with CD. Fifty-eight children (mean age 8.6 ± 4.1 years) were included. The participants were divided into groups based on the time following a GFD: <6 months (n = 18) versus ≥12 months (n = 37). Their dietary consumption was assessed through a three-day food record. The 20-item Celiac Disease Quality Of Life survey (CD-QOL), which contains four subscales (limitations, dysphoria, health concerns, and inadequate treatment) was used to assess the quality of life. The children who followed a GFD for ≥12 months presented poorer scores in the limitations subscale than those who followed a GFD for <6 months (p = 0.010). The mean % of the energy intake from ultra-processed foods was 47.3 ± 13.5. Children with CD consuming more than 50% of their total energy from ultra-processed foods showed poorer scores for the limitation and inadequate treatment (both, p = 0.019) subscales than their counterparts. According to parents’ perceptions, those children who consumed more than 50% of their energy through ultra-processed foods had more limitations, and their treatment was perceived as less effective.
... Patients with CD may also present with adjacent underlying complications, i.e., failure to thrive, short stature, delayed puberty, tiredness, loss of weight, muscle mass, and fat mass but 10% of the patients with CD can be obese, and therefore they should not be overlooked. CD may also present with various gastrointestinal complaints, i.e., diarrhea, cramping, bloating, flatulence, nausea, and electrolyte imbalance (7,8). There are certain non-classical symptoms of CD, such as iron deficiency anemia, increased transaminases, constipation, ataxia, lethargy, osteoporosis, and dyspepsia (9). ...
Background
Celiac disease (CD) was considered a rare disease before and was perceivably only limited to children but now affects almost 1–2% of the global population. This abrupt increase in prevalence is due to advancements in diagnostic criteria and medical facilities but still many countries lack the basic data that can assess the severity of this health issue. The present study was conducted with the aim to assess the common but rarely diagnosed condition with the identification of its underlying secondary ailments.
Materials and methods
Patients visiting public sector hospitals were recruited and tested for clinical symptoms secondary to gluten-containing foods (wheat and barley, etc.), followed by serological testing for immunoglobulin A, tissue transglutaminase A, and anti-endomysial antibodies. Only seropositive candidates were included in the endoscopic and biopsy examination for the features of villous atrophy and intestinal cell damage. The secondary ailments including anemia, growth retardation, and gastrointestinal symptoms were also documented for the tested positive patients. The modified European Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) criterion was followed throughout the study.
Results
From 647 suspected cases from March 2018 to July 2019, 113 were confirmed with CD while 58% were female children and 42% were male children. The majority of them were from a lower class (75%) and 26% of them had a positive family history of CD. A total of 67% of patients with CD were underweight while wasting was observed in 38%, and 80% were stunted as well. Of the positively tested patients with CD, 49% had moderate anemia with 15% having severe anemia. Approximately 33% had hypoalbuminemia as well. The majority of them had a mild to severe range of gastrointestinal symptoms, such as abdominal pain, diarrhea, flatus, eructation, diarrhea, and steatorrhea.
Conclusion
The study finding indicates an increased number of patients diagnosed with CD with an excessive sum of secondary ailments, such as anemia, growth failure, growth retardation, malnutrition, and gastrointestinal symptoms.
... 2 Patients may present with a variety of symptoms including, but not limited to, abdominal pain, diarrhea, steatorrhea, fatigue, weight loss and bloating. 3 Diagnostic evaluation for CD patients includes serology testing for IgA anti-tTG antibodies, IgG anti-tTG antibodies with serum IgA levels (if a patient is suspected to be IgA de cient) and duodenal biopsy with histological analysis. To con rm a diagnosis of CD, patients must be on a gluten-containing diet prior to serology testing. ...
Background
Celiac disease (CD) is caused by an immune response to gluten and treatment is adherence to a gluten-free diet. Guidelines from studies in large academic settings recommend registered dietitian (RD) referrals at time of diagnosis and periodic testing for micronutrient deficiencies. There is limited data to guide follow-up parameters in a large, community-based practice. The purpose of this study was to evaluate guideline adherence in this setting.
Methods
This retrospective study assessed CD care based on follow-up rates, micronutrient testing, symptoms, and serology results in cohorts with and without RD referrals. Patients in this study are followed at Rockford Gastroenterology Associates (RGA): a large, private GI practice. Patients were included if they had a diagnosis from 1/2014 through 12/2018, based on positive serology and/or duodenal biopsy. Patient data was collected by chart review and analyzed through Microsoft Excel. Fisher’s exact and Chi-square tests were used for the statistical analysis.
Results
A cohort of 126 patients met inclusion criteria. 69.8% had a RD referral. 65.9% had at least one lab test order for any of the 6 micronutrients. Of 63 patients tested for iron, 11 were iron deficient (8 with RD referral). Of 64 patients tested for vitamin D, 21 were deficient (17 with referral). 80.2% attended at least one follow-up appointment, but 34.9% had only one follow-up visit over a mean follow up duration of 5.82 months. 79 patients had follow-up data for symptoms or serology and were separated into 4 categories (with vs without RD referral): 1) asymptomatic and negative serology (32% vs 26%), 2) symptomatic and negative serology (28% vs 16%), 3) asymptomatic and positive serology (27% vs 32%), 4) symptomatic and positive serology (13% vs 26%). Category 1 yielded a fisher exact test value of 2.62 (p = .466).
Conclusions
RD referral, micronutrient testing, and close follow-up are important parameters that affect outcomes in patients with CD. Rates for dietitian referral, some micronutrient testing and follow-up visits were higher than 50%, though results from this study were not statistically significant. Further standardization of follow-up testing and monitoring for CD will help minimize discrepancies between community-based and large, academic GI practices.
... In a US cohort consisting of 215 patients, nausea was reported by 42% of participants before dietary treatment and vomiting occurred in a fifth of these patients. These symptoms usually show remission with the follow-up of a gluten-free diet (Murray et al., 2004). ...
Celiac disease is a systemic, chronic and autoimmune disorder that affects genetically susceptible individuals. Due to the increasing incidence of this pathology and the precision of new detection methods, celiac disease diagnosis has improved dramatically in recent years. Hereby, a study was performed to evaluate celiac disease's prevalence, attending to associated diseases as well as clinical determinants. A convenience sample of 254 patients diagnosed between 2007 and 2017 in the South of Spain was selected: 212 were confirmed for celiac disease, 18 remained with suspected celiac disease and 24 were considered silent patients. Multivariate logistic regression models were applied to patients' data. 95.3% of the subjects obtained a positive result in the genetic-molecular diagnosis, with prevalence of female patients' group (58.7%). Moreover, females were associated with diarrhea and abdominal pain to a greater extent (54.3% and 66.2%, respectively). Youngsters had accused villi atrophy and larger concentrations of anti-tTG antibodies compared to adults, but had more adhesion to treatment and recovered better than the older group. Deficit in Fe and multimorbidity were also factors associated with villi atrophy. The multivariate analysis adjusted for sex and age showed a direct association between intestinal lesion and Fe deficit, the presence of vomiting and the number of diseases associated with celiac disease. Novel results of the present study refer to the association between the level of intestinal injury and the multimorbidity associated with celiac disease.
... The mainstay of celiac disease treatment is lifelong adherence to a strict gluten-free diet. Improvement in symptoms typically occurs within days to weeks, and often precedes normalization of serologic markers and duodenal villus atrophy [58]. Multiple studies have suggested that older patients with celiac disease can adhere to a gluten-free diet at a similar rate relative to their younger counterparts [7,11]. ...
Purpose of Review
This review highlights literature from the past several years and explores the impact on current understanding of celiac disease diagnosis, complications, and management in older adults.
Recent Findings
Celiac disease in the elderly is becoming increasingly prevalent but remains underdiagnosed, with a high potential burden of downstream morbidity and modestly increased risk of mortality. Clinical presentations are often related to extraintestinal symptoms and can be subtle. Duodenal biopsy remains the gold standard for diagnosis in older adults, along with supporting serologies. Refractory celiac disease is a particular concern in the aging population, and treatment for this rare condition remains unsatisfactory. Older adults exhibit lower rates of mucosal healing, though the reasons for this are poorly understood.
Summary
Current understanding of celiac disease in the elderly continues to advance, though significant knowledge gaps persist. Large, prospective studies are needed to further characterize celiac disease pathogenesis, complications, and management in older adults.
... Improvement of coeliac-related symptoms on a GFD is an encouraging marker of treatment response and can occur within days to weeks. 72 Poor clinical response coupled with poor GFD adherence is linked to a high risk of persistent villous atrophy (46%; 95% CI 25-68). 73 However, in isolation, the presence or absence of symptoms on a GFD are poor predictors of mucosal healing 74 ...
Coeliac disease is a lifelong immune‐mediated enteropathy with systemic features associated with increased morbidity and modestly increased mortality. Treatment with a strict gluten‐free diet improves symptoms and mucosal damage but is not curative and low‐level gluten intake is common despite strict attempts at adherence. Regular follow‐up after diagnosis is considered best‐practice however this is executed poorly in the community with the problem compounded by the paucity of data informing optimal approaches. The aim of dietary treatment is to resolve symptoms, reduce complication risk and improve quality of life. It follows that the goals of monitoring are to assess dietary adherence, monitor disease activity, assess symptoms and screen for complications. Mucosal disease remission is regarded a key measure of treatment success as healing is associated with positive health outcomes. However, persistent villous atrophy is common, even after many years of a gluten‐free diet. As the clinical significance of asymptomatic enteropathy is uncertain the role for routine follow‐up biopsies remains contentious. Symptomatic non‐responsive coeliac disease is common and with systematic follow‐up a cause is usually found. Effective models of care involving the gastroenterologist, dietitian and primary care doctor will improve the consistency of long‐term management and likely translate into better patient outcomes. Identifying suitable treatment targets linked to long‐term health is an important goal.
... To date, the clinical use of dietary therapy to treat human inflammatory disease has shown the most efficacy in patients with coeliac disease, in which pathogenesis is inherently linked to consumption of wheat. Following a strict gluten-free diet improves coeliac disease pathology characterised by a reduction in intestinal damage, steatorrhea, diarrhoea and weight loss (245,246). However, there is an emerging body of evidence that highlights clinical value in other gastrointestinal and peripheral inflammatory diseases. ...
Diet is an important lifestyle factor that is known to contribute in the development of human disease. It is well established that poor diet plays an active role in exacerbating metabolic diseases, such as obesity, diabetes and hypertension. Our understanding of how the immune system drives chronic inflammation and disease pathogenesis has evolved in recent years. However, the contribution of dietary factors to inflammatory conditions such as inflammatory bowel disease, multiple sclerosis and arthritis remain poorly defined. A western diet has been associated as pro-inflammatory, in contrast to traditional dietary patterns that are associated as being anti-inflammatory. This may be due to direct effects of nutrients on immune cell function. Diet may also affect the composition and function of gut microbiota, which consequently affects immunity. In animal models of inflammatory disease, diet may modulate inflammation in the gastrointestinal tract and in other peripheral sites. Despite limitations of animal models, there is now emerging evidence to show that anti-inflammatory effects of diet may translate to human gastrointestinal and inflammatory diseases. However, appropriately designed, larger clinical studies must be conducted to confirm the therapeutic benefit of dietary therapy.
... However, after this period a return of symptoms was observed in vt12, which indicated the probable relaxation of these participants in strictly following the GFD. In fact, the literature also indicates that dietary adherence to GFD can decrease with the duration of treatments [88,89] and the greater the level of adherence, the more effective the GFD is in resolving symptoms [90,91]. Symptoms reported by participants as having decreased at the beginning but recurring by the end of the intervention, indicate that the concern about both the diet and the presence of symptoms was not as important at the end as at the beginning. ...
The present work aimed to analyze, through the GlutenFreeDiet digital platform, the evolution over one year of the nutritional status, dietary profile and symptoms present among celiac people on a gluten-free diet (GFD) while receiving individualized dietary advice. Twenty-seven adults and thirty-one celiac children/adolescents participated in the study. This was then followed up by three visits, at diagnosis, and after 3 and 12 months (vt0, vt3 and vt12). Participants filled out dietary and gastrointestinal symptoms questionnaires. All patients received written personalized dietary advice from dietitians who interpreted data from the platform. Results obtained indicated that participants consumed proteins and lipids in excess and carbohydrates in defect. Low intakes of cereals, fruit and vegetables and high meat intakes were observed. However, gluten-free product (GFP) consumption and that of ultra-processed foods was reduced after 1 year in adults. Symptoms decreased after vt3 but recurred in vt12. Changes in ultra-processed foods and GFP intake, but lack of changes in the rest of the parameters suggested that the platform support was not effective enough. Even though the platform represents a useful tool for monitoring celiac patients and giving dietary advice, modules that require more continuous attention and nutritional education of patients should be provided for interventions to be more effective.
... Symptoms of celiac disease include bloating, vomiting and diarrhoea (Skerritt et al. 1990). There is also another condition called nonceliac gluten sensitivity, which incurs similar symptoms such as bloating, gas, abdominal pain, weight loss due to malabsorption, anaemia and fatigue (Murray et al. 2004;Ghadami 2016). Celiac disease occurs due to the particular genes, including HLA -DQ2 and DQ8 Haplotype. ...
Gluten intolerance is one of the significant symptoms associated with different health disorders, which has become an increasing concern worldwide. A gluten-free diet is considered a curative product for the problem, which has been steadily increasing in the market. Gluten plays a key role in developing gluten-containing products with desired attributes. Elimination of gluten in staple food is not an easy task and it is difficult to provide the gluten-free product with similar characteristics as gluten-based products. Gluten-free products are produced from gluten-free cereals with different kinds of additives that modify the product according to the desired properties. Gluten-free cereals such as rice, sorghum, maize, and corn are some of the raw materials that are the major replacement cereals for producing gluten-free products. Fermentation is also an avital step in the preparation of the gluten-based product for attaining optimum texture and sensory properties. Sourdough fermentation is an important process employed in the fermentation of gluten-free products for creating resemblance with the gluten-based product. Lactic acid bacteria species have been mostly used in the fermentation process to produce gluten-free products of equivalent quality. Enzymes are also utilized in the production of non-gluten products such as gluten-free beer. The major drawbacks of gluten-free products include the cost of production, nutritional deficiency, and lack of simpler methods to produce the final products. Lack of nutrients in gluten-free products is due to the replacement of raw materials that can be recovered by the incorporation of nutrients from different sources such as vegetables and grains containing vitamins, minerals, and high-level dietary fiber. The modification of physical, chemical, and aromatic properties by the incorporation of additives also influences the final product quality. The future market scenario mainly depends on the adaptation of new lifestyle diets by the respective consumers for the respective abnormality and disease.
... Gluten, a protein found in wheat, is not present in GF flour (e.g., rice, tubers, maize, millet, sorghum, etc.), causing the cooking quality and texture of GF pasta to be unacceptable. Gluten is an essential ingredient to build protein structure, which holds the starch in place and forms a protein network (Murray et al.,2004 andMariotti et al.,2011). Gluten is a fundamental property to build dough's viscoelastic characteristics (Mariotti et al.,2011). ...
The aim of this study was to determine the quality attributes of chickpea enriched rice noodles. Black rice-chickpea pastas were produced from different blends 10-30% of chickpea flour and black rice flour. The protein, fat, ash, Ca, Mg and P content were observed higher for chickpea flour. The noodles' proximate composition, cooking quality, and sensory characteristics were determined. Results showed an increment in protein content (9.23-16.54 %), fat (2.64-4.14 %) and ash (1.91-2.71 %). Fortification with chickpea flour reduced cooking time (8.5-7.32 min) but increased cooking loss from 2.48 to 4.18 %. Black rice noodles enriched with 30% chickpea flour was highly ranked for sensory attributes. Chickpea flour can be successfully using in the noodles formula and improving the nutritional quality of noodles. In conclusion, this study found that black rice-chickpea noodles are a nutritional alternative to traditional rice noodles, as well as providing variety to dietary categories for celiac disease sufferers.
... Gluten, a protein found in wheat, is not present in GF flour (e.g., rice, tubers, maize, millet, sorghum, etc.), causing the cooking quality and texture of GF pasta to be unacceptable. Gluten is an essential ingredient to build protein structure, which holds the starch in place and forms a protein network (Murray et al.,2004 andMariotti et al.,2011). Gluten is a fundamental property to build dough's viscoelastic characteristics (Mariotti et al.,2011). ...
The aim of this study was to determine the quality attributes of chickpea enriched rice noodles. Black rice-chickpea pastas were produced from different blends 10-30% of chickpea flour and black rice flour. The protein, fat, ash, Ca, Mg and P content were observed higher for chickpea flour. The noodles' proximate composition, cooking quality, and sensory characteristics were determined. Results showed an increment in protein content (9.23-16.54 %), fat (2.64-4.14 %) and ash (1.91-2.71 %). Fortification with chickpea flour reduced cooking time (8.5-7.32 min) but increased cooking loss from 2.48 to 4.18 %. Black rice noodles enriched with 30% chickpea flour was highly ranked for sensory attributes. Chickpea flour can be successfully using in the noodles formula and improving the nutritional quality of noodles. In conclusion, this study found that black rice-chickpea noodles are a nutritional alternative to traditional rice noodles, as well as providing variety to dietary categories for celiac disease sufferers.
... Gluten, a protein found in wheat, is not present in GF flour (e.g., rice, tubers, maize, millet, sorghum, etc.), causing the cooking quality and texture of GF pasta to be unacceptable. Gluten is an essential ingredient to build protein structure, which holds the starch in place and forms a protein network (Murray et al.,2004 andMariotti et al.,2011). Gluten is a fundamental property to build dough's viscoelastic characteristics (Mariotti et al.,2011). ...
The aim of this study was to determine the quality attributes of chickpea enriched rice noodles. Black rice-chickpea pastas were produced from different blends 10-30% of chickpea flour and black rice flour. The protein, fat, ash, Ca, Mg and P content were observed higher for chickpea flour. The noodles' proximate composition, cooking quality, and sensory characteristics were determined. Results showed an increment in protein content (9.23-16.54 %), fat (2.64-4.14 %) and ash (1.91-2.71 %). Fortification with chickpea flour reduced cooking time (8.5-7.32 min) but increased cooking loss from 2.48 to 4.18 %. Black rice noodles enriched with 30% chickpea flour was highly ranked for sensory attributes. Chickpea flour can be successfully using in the noodles formula and improving the nutritional quality of noodles. In conclusion, this study found that black rice-chickpea noodles are a nutritional alternative to traditional rice noodles, as well as providing variety to dietary categories for celiac disease sufferers.
Background
Several organizations have proposed guidelines or clinical decision tools for the management of patients with disorders of gut‐brain interactions (DGBI) affecting the lower digestive tract including irritable bowel syndrome and chronic idiopathic constipation. Such algorithms are based on sequential therapeutic trials and modifying the treatment strategy based on efficacy and adverse events.
Purpose
The aims of this review are to evaluate the evidence for efficacy of second‐ and third‐line pharmacotherapies and to assess the evidence for the alternative option to manage subgroups of patients with symptoms suggestive of lower DGBI based on diagnostic tests or documented dysfunctions. The preeminent tests to identify such subgroups that present with symptoms that overlap with lower DGBI are detailed: digital rectal examination as well as anorectal manometry and balloon expulsion for evacuation disorders, detailed measurements of colonic transit, and diagnosis of bile acid diarrhea or carbohydrate malabsorption based on biochemical measurements. The review also addresses the cost implications of screening to exclude alternative diagnoses and the costs of therapy associated with the therapeutic options following an algorithmic approach to treatment from the perspective of society, insurer, or patient. Finally, the costs of the diagnostic tests to identify actionable biomarkers and the evidence of efficacy of individualized therapy based on formal diagnosis or documentation of abnormal functions are detailed in the review.
Goals and Background
Gluten-free diet (GFD) includes a higher intake of sugars and fats. Previous studies have investigated its effect on body mass index (BMI) in celiac disease (CD) patients but had contradictive conclusions. Thus, we conducted a systematic review and meta-analysis examining the effect of GFD on BMI in CD patients.
Study
Systematically, we conducted literature research using Medline, Scopus, and Embase, and we identified 1565 potential studies/abstracts. Only studies of patients with CD under a GFD with recorded BMI before and after dietary intervention were included. Subgroup analyses based on study design and BMI categories were performed. We calculated the pooled odds ratios (ORs) and 95% confidence intervals (Cls) for the number of patients in each BMI group according to the World Health Organization (WHO) definitions after GFD using fixed and random effect meta-analysis.
Results
The analysis included 10 studies and 38 sub-studies/data sets, which encompassed 2450 patients from 5 countries. We found nonsignificant odds for changing the BMI group (pooled OR 0.972, 95% CI: 0.858-1.101, P =0.65) after GFD. However, looking specifically at BMI subgroups, we found higher odds for BMI category change after GFD in underweight patients (OR 0.588, 95% CI: 0.479-0.723, P <0.001), and overweight patients,25<BMI<30, (OR 1.332, 95% CI: 1.167-1.521, P <0.001). No publication bias was demonstrated, and the amount of heterogeneity between studies was moderate ( I ² =54.13).
Conclusion
Although crucial in patients with CD, GFD is associated with increased BMI in some CD patient populations. Accordingly, special considerations and follow-up should be maintained in overweight patients with CD after GFD.
The field of pediatric gastroenterology is a specialty that has rapidly grown from being offered at a few select centers around the world to one that is now considered an absolute necessity at any pediatric hospital. In the United States, there is ~1 pediatric gastroenterology provider per 100,000 children making it one of the largest pediatric subspecialty disciplines. However, due to patient volume, it is considered by the Children’s Hospital Association to be a subspecialty with a shortage of providers. With rapid growth comes considerable change in practice management and technological advancement. Given the frequency of gastrointestinal complaints (such as reflux, constipation, weight concerns and elevated transaminase levels) and the relative shortage of subspecialty providers, it is important for primary care providers to be up to date on common pediatric gastrointestinal and hepatology advancements. In this chapter we have highlighted some of the most important changes and advancements pertaining to common pediatric gastrointestinal and hepatic conditions that have occurred over the last 5–10 years and presented in a manner to best aid the primary care provider.
Coeliac disease (CD) is an autoimmune disorder that occurs in genetically predisposed individuals who develop an immune reaction to gluten. The disease primarily affects the small intestine; however, the clinical manifestations are broad, with both intestinal and extra-intestinal symptoms [1]. CD provides a model of an immune-based disease with strong genetic and environmental risk factors. The key environmental factor responsible for the development of CD is gluten. Gluten is incompletely digested by gastric, pancreatic and brush border peptidases, leaving large peptides up to 33 amino acids long. These peptides enter the lamina propria where, in pre-disponed people, an adaptive immune reaction occurs, is dependent on deamidation of gliadin molecules by the enzyme tissue transglutaminase (TTG), the predominant autoantigen of CD [2]. Deamidation increases the immunogenicity of gliadin, facilitating binding to the HLA-DQ2 or HLA-DQ8 molecules on antigen presenting cells. Gliadin peptides are then presented to gliadin-reactive CD4+ cells. During this process, antibodies against TTG, gliadin and actin are made through unclear mechanism. Almost 100% of patients with CD possess specific variants of the HLA class II genes HLA-DQA1 and HLA-DQB1 encoding the alpha and beta chains making up the coeliac-associated heterodimer proteins DQ2 and DQ8 expressed on the surface of antigen presenting cells. These HLA genes and gluten ingestion are quite common in Caucasian people but CD occurs only in about 1% of the population, suggesting that other environmental factors besides gluten are probably important.
The gluten-free diet (GFD) remains a complex paradigm in managing celiac disease (CeD) in children and adults, and there are many reasons why GFD adherence should be strict to improve outcomes. However, this is a challenging task for patients, since they need to have access to quality healthcare resources that facilitate optimal GFD adherence. Understanding the strengths and weaknesses of the GFD, tackling coexisting nutritional deficiencies, and dealing with complex situations, such as seronegative CeD or non-responsive CeD, all require the involvement of a multidisciplinary team. The short- and long-term follow-up of CeD patients should preferably be performed by a combined Gastroenterology and Nutrition service with well-defined quality standards and the multidisciplinary involvement of physicians, nurses, dietitians, and psychologists. Nutritional advice and counseling by an experienced dietitian can reduce the costs associated with long-term follow-up of CeD patients. Likewise, psychological interventions may be essential in specific scenarios where implementing and sustaining a lifelong GFD can cause a significant psychological burden for patients. This manuscript aims to provide guidelines to improve clinical practice in the follow-up and monitoring of CeD patients and provide information on the nutritional risks of an ill-advised GFD. Clinicians, biochemists, food technologists, dietitians, and psychologists with a global view of the disease have been involved in its writing.
Background
The gluten-free diet (GFD), the only effective treatment for celiac disease, is usually nutritionally imbalanced. The present work aimed to analyze the evolution of the nutritional status, dietary profile, and symptoms present among celiac people over one year on a GFD while receiving individualized dietary advice.
Methods
Twenty-seven adults and thirty-one celiac children/adolescents participated in the cohort study. They were followed by 3 visits, at diagnosis (vt0) and after 3 and 12 months (vt3;vt12). Participants filled out dietary and gastrointestinal symptoms questionnaires and received a personalized form from dietitians containing dietary advice and anthropometric and biochemical data evolution.
Results
Most patients presented normal BMI, fat and muscle mass, and biochemical parameters at diagnosis and vt12. By contrast, all participants consumed protein and lipids in excess and carbohydrates in defect, in both vt0 and vt12. Low intakes of cereals, fruits and vegetables and high of meat were observed, these also remain-ing unchanged after dietary counseling. Symptoms present decreased after vt3 but rebounded in vt12.
Conclusions
Few changes in dietary pattern and symptom elimination suggested that the intervention was not effective enough. More research is necessary to evaluate whether closer follow up and face-to-face dietary advice improve dietary habits of celiac people.
Trial registration
Code PI2016069, Ethical Comitee of the Clinical Investigation of the Basque Country. Registered on 15 July 2016.
This guideline presents an update to the 2013 American College of Gastroenterology Guideline on the Diagnosis and Management of Celiac Disease with updated recommendations for the evaluation and management of patients with celiac disease (CD). CD is defined as a permanent immune-mediated response to gluten present in wheat, barley, and rye. CD has a wide spectrum of clinical manifestations that resemble a multisystemic disorder rather than an isolated intestinal disease, and is characterized by small bowel injury and the presence of specific antibodies. Detection of CD-specific antibodies (e.g., tissue transglutaminase) in the serum is very helpful for the initial screening of patients with suspicion of CD. Intestinal biopsy is required in most patients to confirm the diagnosis. A nonbiopsy strategy for the diagnosis of CD in selected children is suggested and discussed in detail. Current treatment for CD requires strict adherence to a gluten-free diet (GFD) and lifelong medical follow-up. Most patients have excellent clinical response to a GFD. Nonresponsive CD is defined by persistent or recurrent symptoms despite being on a GFD. These patients require a systematic workup to rule out specific conditions that may cause persistent or recurrent symptoms, especially unintentional gluten contamination. Refractory CD is a rare cause of nonresponsive CD often associated with poor prognosis.
Celiac disease (CD) is an intestinal autoimmune disorder developed in genetically susceptible individuals upon gluten ingestion. Gliadin is known to be the most immunogenic gluten component, which can activate the host immune response represented by NFkB activation and release of proinflammatory cytokines as IL8. However, many aspects of the involvement of gliadin in CD pathophysiology is not well understood yet. Lack of a CD animal model increases difficulty elucidating key steps in CD development, what increases the importance of in vitro experiments. Here we present a protocol for in vitro pepsin-trypsin digested gliadin (PTG) treatment for long term studies in HCT116 intestinal cell line.
Introduction
Coeliac disease and dermatitis herpetiformis are immune-mediated diseases triggered by the consumption of gluten in genetically predisposed individuals. These guidelines were developed to provide general practitioners, paediatricians, gastroenterologists, and other clinicians with an overview on the diagnosis, management and follow-up of coeliac patients and those with dermatitis herpetiformis.
Methods
Guidelines were developed by the Italian Societies of Gastroenterology. Following a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the certainty of the evidence. Statements and recommendations were developed by working groups consisting of gastroenterologists and a paediatrician with expertise in this field.
Results
These guidelines provide a practical guidance for the diagnosis, management and follow-up of coeliac patients and dermatitis herpetiformis in children and adults, both in primary care and in specialist settings. We developed four sections on diagnosis, gluten-free diet, follow-up and risk of complications in adults, one section focused on diagnosis and follow-up in children and one on the diagnosis and management of dermatitis herpetiformis.
Conclusions
These guidelines may support clinicians to improve the diagnosis and management of patients with coeliac disease.
Background
The best‐known symptoms of coeliac disease are related to the gastrointestinal tract, but the disease may also present with various systemic manifestations outside the intestine. Some of these consequences may remain permanent in undiagnosed individuals or if the diagnostic delay is prolonged. However, for many of the systemic manifestations, the scientific evidence remains scant and contradictory.
Aims and Methods
We conducted a narrative review of the most thoroughly studied and clinically relevant systemic consequences of coeliac disease, especially those that could be prevented or alleviated by early diagnosis. The review is intended particularly for physicians encountering these patients in daily clinical practice.
Results
The possible systemic consequences of coeliac disease extend to multiple organ systems, the best studied of which are related to skeletal, reproductive, cardiovascular and neurological systems. Furthermore, the disease is associated with an elevated risk of psychiatric comorbidities, non‐Hodgkin lymphomas and intestinal adenocarcinoma.
Conclusions
The various systemic consequences of coeliac disease play a significant role in the overall health of patients. Early diagnosis and treatment with a gluten‐free diet appear to be beneficial for most, but not all of these conditions. The possible negative metabolic and psychosocial effects of the diet should be acknowledged during follow‐up.
Introduction and aim
To characterize a university hospital population of Chilean adult patients with celiac disease.
Patients and method
We retrospectively reviewed the records of patients under control that were diagnosed with celiac disease through clinical characteristics, serology, and histology.
Results
A total of 149 patients were included, 119 (79.9%) of whom were women. Mean patient age was 42 years at diagnosis and 13.4% of patients had a family history of celiac disease. Mean body mass index was 24.3 kg/m², 55.3% presented with normal weight, 37.9% with overweight and obesity, and 6.8% with underweight. The main reasons for consultation were diarrhea (47%), weight loss (31%), dyspepsia (43%), and fatigue (26.1%). Anemia (26.1%), elevated transaminases (17.4%), low ferritin (11.4%), and hypovitaminosis D (9.3%) stood out, among others, in the initial laboratory work-up. The more frequent associated diseases were hypothyroidism (15.4%) and depressive disorder (11.4%). Small intestinal bacterial overgrowth was found in 10.1% and lactose malabsorption in 15.4%. The primary histologic diagnosis was celiac disease, with Marsh stage 3a villous atrophy (34.9%).
Conclusion
Our results were similar to those of other case series on adults, finding that celiac disease was more frequent in women, disease began in the fourth decade of life, extraintestinal symptoms predominated, and there was an association with other autoimmune diseases. An important percentage of patients were also overweight and obese.
Background
IBS affects a large number of children throughout the world and is thought to be the result of disturbed neuroimmune function along with the brain–gut axis. Although the underlying pathophysiologic mechanisms are not clear, the role of low‐grade inflammation and mucosal immune activation in IBS symptom generation has become evident also in subsets of pediatric patients. Animal models provided meaningful insight in the causal relationship between abnormal mucosal immune activation and changes in gastrointestinal (GI) sensory‐motor function. Likewise, the development of long‐standing GI symptoms fulfilling the current criteria for functional GI disorders after infection gastroenteritis and in patients with IBD or celiac disease in remission further supports this hypothesis. Immune activation, its impact on gut sensory‐motor function, and potential implications for symptom generation emerged in both children and adults with IBS.
Purpose
The aim of this review is to summarize the main evidence on the presence of low‐grade inflammation and immune activation in children with IBS, its possible role in symptom generation, and its potential implication for new therapeutic strategies.
Resumen
Introducción y objetivo
Caracterizar una población chilena de enfermos celiacos adultos de un centro universitario.
Pacientes y método
Se revisaron de manera retrospectiva los expedientes de pacientes en control con diagnóstico de enfermedad celiaca (EC) por clínica, serología e histología.
Resultados
Se incluyeron 149 pacientes, de los que 119 eran mujeres (79.9%), con una edad promedio de 42 años al momento del diagnóstico. El 13.4% de los pacientes tenían antecedentes familiares de EC. Índice de masa corporal promedio de 24.3 kg/m²: peso normal el 55.3%, sobrepeso y obesidad el 37.9% y bajo peso el 6.8%. Los principales motivos de consulta fueron: diarrea (47%), baja de peso (31%), dispepsia (43%) y fatiga (26.1%). En el laboratorio inicial destacaron anemia (26.1%), transaminasas elevadas (17.4%), ferritina baja (11.4%) e hipovitaminosis D (9.3%), entre otros. Las patologías asociadas más frecuentes fueron hipotiroidismo (15.4%) y trastorno depresivo (11.4%). Se encontró sobrecrecimiento bacteriano en el 10.1% y malabsorción de lactosa en el 15.4%. El principal diagnóstico histológico fue de EC con atrofia de vellosidades estadio 3a de Marsh (34.9%).
Conclusión
Nuestros resultados son similares a los de otras series en adultos, que reportan que la EC es más frecuente en mujeres, con inicio en la cuarta década de la vida, con predominio de síntomas extraintestinales y asociado con otras enfermedades autoinmunes. Existe un porcentaje importante en pacientes con sobrepeso y obesos.
Arthritis has often been alluded to as an extra-intestinal clinical manifestation of coeliac disease, but definitive data regarding its prevalence are still lacking. We therefore evaluated the overall prevalence of articular involvement in 200 consecutive adult coeliac patients attending routine gastroenterology follow-up and in 40 controls, and determined whether the prevalence and pattern of articular involvement varied according to the dietary status. An arthritis was present in 26% of patients and in 7.5% of controls, prevalences ranging from 41% in patients on a regular diet to 21.6% in patients on a gluten-free diet (P < 0.005). Arthritis was peripheral in 19 patients, axial in 15 and an overlap of both in 18 subjects. These data suggest that arthritis is much more common than previous reports have indicated, particularly in patients receiving an appropriate dietary regimen, and support the need for combined gastrointestinal and rheumatological follow-up in coeliac patients.
The clinical spectrum of adults with celiac disease in the United States, where the disease is considered rare, is not known. We sought this information by distributing a survey.
A questionnaire was distributed by way of a celiac newsletter, directly to celiac support groups, and through the Internet.
Respondents (1,612) were from all United States except one. Seventy-five percent (1,138) were biopsy proven. Women predominated (2.9:1). The majority of respondents were diagnosed in their fourth to sixth decades. Symptoms were present a mean of 11 yr before diagnosis. Diarrhea was present in 85%. Diagnosis was considered prompt by only 52% and 31% had consulted two or more gastroenterologists. Improved quality of life after diagnosis was reported by 77%. Those diagnosed at age > or = 60 yr also reported improved quality of life. Five respondents had small intestinal malignancies (carcinoma 2, lymphoma 3) accounting for a relative risk of 300 (60-876) for the development of lymphoma and 67 (7-240) for adenocarcinoma.
Patients with celiac disease in the United States have a long duration of symptoms and consider their diagnosis delayed. Improved quality of life after diagnosis is common. An increased risk of developing small intestine malignancies is present.
The clinical aspects of coeliac disease before and after anti-gliadin antibodies (AGA) assessment in clinical practice, referring to personal experience (107 cases in the period 1976-1988) are described. AGA determination has executed by two different ELISA methods. The diagnosis of coeliac disease in the period 1976-1986 has been made according to ESPGAN criteria, while in the last two years following the recent SIP advice. After 1987 with the introduction of AGA assay, the number of diagnosis/year of coeliac disease has increased three times in respect of the period 1976-1986. We have observed a more marked increase of the late beginning forms (from 2.8 to 10 diagnosis/year) in respect of the early beginning ones (from 3.7 to 7.5 diagnosis/year) and of the atypical forms (from 0.7 to 9 diagnosis/year) in respect of the typical ones (from 5.8 to 8.5 diagnosis/year). According to these data we think that prevalence of coeliac disease in our country is probably underestimated. AGA determination is at time most effective mean to make a screening of coeliac disease in the population. According to us the largest employment of this method in the next years could take a most exact estimate of the coeliac disease prevalence in our country.
Persistent pica may be either a cause or a result of iron deficiency. Three children are described with long-standing pica and iron-deficiency anemia and in whom total villous atrophy consistent with celiac disease was found on jejunal biopsy. Additional findings included short stature, delayed bone age, and impaired xylose absorption. A dramatic growth spurt and complete resolution of pica were observed after a gluten-free diet. In these cases pica evidently resulted from iron deficiency secondary to malabsorption. Underlying celiac disease should be considered in children with persistent pica and growth failure even if gastrointestinal disturbances are minimal.
We report the clinical, laboratory, and pathological findings in a series of 52 consecutive patients with adult celiac sprue observed over a 20-year period. The frequency of that diagnosis increased from an average of 0.7 case/year during the period 1966-1975 to 5.8 cases/year during the period 1981-1985. Apart from two patients with dermatitis herpetiformis, nonclassical clinical presentations were observed in 16 of 50 (32%) patients overall and in 13 of 28 (46%) patients diagnosed since 1981. Diarrhea was the most common complaint leading to the diagnosis; since 1981, hematologic abnormalities warranted investigation in 38% of the patients. Decreased iron stores (88%), decreased red cell folate (82%), or both (74%), and abnormal radiographic studies of the small bowel (83%) were the most sensitive tests in the diagnostic investigation. We conclude that atypical or nonclassical presentations of adult celiac sprue, mostly with hematologic abnormalities, are not uncommon.
Study of twenty-one cases of gluten-induced enteropathy emphasized that the clinical expressions are highly variable and may be subtle or occult. The classic features of diarrhea, weight loss, steatorrhea and malnutrition were the predominant features in only eight patients (38 per cent). Other presenting problems included thrombophlebitis, megaloblastic anemia of pregnancy, edema, tetany, nonspecific gastrointestinal symptoms, bone pain and diarrhea associated with diabetes or occurring after abdominal surgery. Laboratory abnormalities were often minimal or mild. Steatorrhea was present in only thirteen of twenty patients (65 per cent). Intestinal disaccharidase activities were low in twelve untreated patients. The mean seru immunoglobulin M (lgM) level was significantly diminished in twelve patients studied. One patient had a selected serum and exocrine lgA deficiency. In three patients a roentgenographic malabsorption pattern was the initial clue to the diagnosis.
To address the frequency and outcome of celiac disease in a United States community.
We identified all Olmsted County, Minnesota, residents diagnosed with this condition during the period, 1960 through 1990, using the resources of the Rochester Epidemiology Project. Twenty-eight incident cases (19 women, nine men) were identified.
The overall age- and gender-adjusted incidence of celiac disease in the community was 1.2 per 100,000 person-yr (95% CI 0.7, 1.6). There were no significant changes in incidence over time, although rates did increase; the incidence was similar in men and women and rose with age in both genders (p < 0.05). Survival in this inception cohort was 100% at 6 months and 96% at 5 yr, which was not significantly different from expected. The estimated prevalence on January 1, 1991, was 21.8 per 100,000.
This study provides the first epidemiologic data on celiac disease in the United States.
The aim of this study was to determine in a homogeneous adult population from Denmark, which is known to have very low incidence rates of coeliac disease, 1) the percentage of patients presenting with mild or atypical symptoms; 2) a possible change in clinical pattern over time; and 3) the delay in diagnosis and the age and sex distribution.
The symptoms, delay in diagnosis, age, sex, and haematologic features of 50 consecutive adult coeliac patients, diagnosed by the same person in a uniform manner, are presented.
The median age was 40.5 (range, 17-82) years. The male to female sex ratio was 1:2.8. The median delay in diagnosis was 3 years. Fifty-eight per cent reported symptoms that could be attributed to coeliac disease during childhood. Presenting symptoms were tiredness, 78%; borborygmus, 72%; abdominal pain, 64%; diarrhoea, 56%; weight loss, 44%; vomiting, 16%; constipation, 12%; bone pain, 12%; and dermatitis herpetiformis, 10%. Weight gain after treatment was experienced by 84%. As a group the coeliac patients had many abnormal blood analysis results, but many patients had several test results inside the normal range. Only 22% had anemia. Liver involvement was not an uncommon feature (19% had increased transaminase levels). Low values were registered in s-iron (32%), p-folate (49%), c-folate (35%), p-vitamin B12 (11%), p-coagulation factors (II, VII, X) (32%), s-protein (21%), s-albumin (26%), s-calcium (43%), p-magnesium (13%), and s-zinc (31%). High/low IgG levels were 3%/8%; high, IgA 21%; high/low IgM, 65%/14%; and high IgE, 71%. The gliadin antibody test was the best screening test (81% positive). No changes in clinical pattern were demonstrated during the period.
The percentage of patients presenting with anaemia (22%) and other haematologic signs of malabsorption was one of the lowest reported ever. This emphasizes the highly variable and subtle clinical expression of adult coeliac disease.
The majority of patients with celiac sprue experience diarrhea before diagnosis. There have been no studies of the prevalence or causes of chronic diarrhea in these patients after treatment with a gluten-free diet.
Seventy-eight patients with celiac sprue (59 women and 19 men) treated with a gluten-free diet for at least 12 months were surveyed about their bowel habits. Those with chronic diarrhea, defined as passage of loose stools three or more times per week for 6 months, underwent an extensive diagnostic evaluation to determine its cause.
Sixty-two of the 78 patients (79%) experienced diarrhea before treatment, and 13 (17%) had chronic diarrhea (of lesser severity) after treatment. The causes of diarrhea in 11 patients consenting to this study were microscopic colitis, steatorrhea secondary to exocrine pancreatic insufficiency, dietary lactose or fructose malabsorption, anal sphincter dysfunction causing fecal incontinence, and the irritable bowel syndrome. Only 1 patient had antigliadin antibodies detected in serum or small intestinal villous atrophy.
After treatment of celiac sprue with a gluten-free diet, chronic diarrhea persists in a substantial percentage of patients. Although ongoing gluten ingestion is one possible cause, other causes may be more frequent. Therefore, diagnostic investigation of diarrhea in celiac sprue after treatment seems warranted.
Recent epidemiologic studies in Europe using antigliadin (AGA) and anti-endomysium antibodies (AEA) for initial screening have shown that the overall prevalence of celiac disease (CD) is about 1:300. There are no comparable scientific data for the USA, where CD is considered rare. The main aim of this study was to determine the prevalence of increased AEA in healthy blood donors in the USA.
Sera from 2000 healthy blood donors were screened for IgG AGA and IgA AGA with an enzyme-linked immunosorbent assay test. All those with increased AGA levels, those with intermediate levels, and random samples with low levels were tested for AEA, using both monkey esophagus (ME) and human umbilical cord (HUC) cryosections as substrates.
The mean age of the blood donors was 39 years, with 52% being men, 85.2% being Caucasian, 11.8% African-American, 1.5% Asian, and 1.5% Hispanic. Eight healthy blood donors had positive AEA tests on both monkey esophagus and human umbilical cord. Among the eight subjects with increased AEA levels seven were Caucasian and one was African-American. All the four examined AEA-positive donors carried the known susceptibility alleles for CD.
The prevalence of increased AEA levels in healthy blood donors in the USA is 1:250 (8:2000). This is similar to that reported in countries in Europe, where subsequent small-intestinal biopsies have confirmed CD in all those with AEA positivity. On the basis of a high positive predictive value of the AEA antibody test, it is likely that the eight blood donors identified in this study have CD. These data suggest that CD is not rare in the USA and that there is need for a large-scale epidemiologic study to determine the precise prevalence of the disease in the USA.
Coeliac disease is common yet often undiagnosed because symptoms may be trivial, non-specific, or non-gastrointestinal, or because of lack of clinician awareness. Serum IgA-class endomysial antibodies (EmA) have high specificity for coeliac disease and may facilitate case-finding by clinicians other than gastroenterologists. We assessed the appropriateness and diagnostic yield of of requests for EmA by primary care general practitioners in a defined geographic area of Northern Ireland.
We identified patients who had EmA examination requests by their general practitioners during 1994-1996. Individual patient questionnaires were posted to the general practitioners concerned, seeking information on indications for testing, management after the result, and final diagnosis. We compared new patient diagnosis rates in two catchment areas, one served by a large district general hospital with, and the other by smaller hospitals without, a medical gastroenterology facility.
A total of 239 patients had coeliac profile testing by 69 of 177 general practitioners in the area. Data were available for 181 patients not previously known to have coeliac disease, of whom 20 (11%) had EmA. All EmA-positive patients were referred to hospital, where 19 underwent small-bowel biopsy, which confirmed coeliac disease in all 19. Only 7 (35%) of the 20 had diarrhoea, and there was no significant difference in EmA prevalence among patients tested with and without diarrhoea. Although the mean number of new patients (per 100,000 population annually) diagnosed by biopsy was 11 at the large hospital compared with 5 elsewhere, the numbers identified by EmA in general practice for the 2 catchment areas were similar (2 and 3, respectively).
General practitioners have an important role in the identification of patients with coeliac disease, particularly where there is no local medical gastroenterology facility, and this is facilitated by EmA testing.
Celiac disease is frequently associated with chronic gastritis. Helicobacter pylori is the main etiologic agent of chronic gastritis. The aim of this study was to assess the prevalence of H. pylori, the related symptoms, and the endoscopic and histologic gastric features in children with celiac disease.
Eight-one (24 boys, 57 girls; age range: 1.4-17.7 years, median 6.8) children with celiac disease were studied. All children had a blood sample taken. In a subgroup of 30 children who underwent endoscopy, three gastric biopsy specimens were taken for histology (hematoxylin and eosin, Giemsa, immunohistochemistry) and urease quick test. Symptom complaints were recorded. Age- and sex-matched (one case, one control) children without celiac disease were used for comparison. Serum H. pylori IgG were measured by means of a locally validated commercial enzyme-linked immunoassay.
Overall, 15 of 81 (18.5%) children with celiac disease and 14 of 81 (17.3%) control children were positive for H. pylori. The percentage of H. pylori positivity was similar in children with untreated and treated celiac disease. Recurrent abdominal pain was the only symptom that helped to distinguish between H. pylori-positive and H. pylori-negative children. However, symptoms disappeared in patients with celiac disease after gluten withdrawal, irrespective of H. pylori status. All endoscopic (erythema, nodularity) and histologic (superficial-, interstitial-, lymphocytic-gastritis, activity, lymphoid follicles) findings did not differ between celiac and nonceliac H. pylori-positive children.
Prevalence and clinical expressivity of H. pylori infection is not increased in children with celiac disease. The clinicopathologic pattern of the infection is not specifically influenced in this condition.
The demographic, clinical, and epidemiological features of subclinical/silent celiac disease in Italy were analyzed in a multicenter study carried out with the participation of 42 centers, in the years between 1990 and 1994.
One thousand twenty-six subclinical/silent patients (644 children and 382 adults, 702 women and 324 men) were considered eligible for the study.
The prevalence of the subclinical/silent form increased significantly during the study both in adults (p < 0.001) and in children (p < 0.005), but its prevalence was always lower (p < 0.001) in children than in adults. This increase appears more likely due to a greater diagnostic awareness and to a better use of screening than to a higher number of subclinical/silent cases. Whereas in 1990 a significantly higher proportion (p < 0.001) of subclinical/silent celiac patients was diagnosed in Northern Italy rather than in Southern-Insular Italy, both in adults (46.7% vs 17.2%) and in children (22.0% vs 9.0%), in 1994 such a difference was no longer conspicuous. Both in children and in adults, iron-deficiency anemia appeared to be the most frequent extraintestinal symptom, followed by short stature in children and cutaneous lesions of dermatitis herpetiformis in adults. In 25.9% of the cases another disease was present, with a significantly higher frequency (p < 0.05) in adults (30.1%) than in children (20.7%). Diabetes and atopy appeared to be the most frequently associated conditions both in children and in adults.
This study has provided an analysis of the largest series of subclinical/silent celiac disease reported to date. In Italy, this form is most frequently recognized in adults, and prospective studies will clarify whether the lower frequency observed in children is a real or apparent phenomenon.
To determine the incidence and presenting features of coeliac disease and dermatitis herpetiformis in the population of South Glamorgan between 1981 and 1995.
Retrospective case-finding study using pathology, dietetic and clinical records, data from hospital activity analysis, general practice records and a Coeliac Society questionnaire. Incidence rates were calculated using the Registrar General's mid-year estimates.
Regional hospitals, South Glamorgan, Wales.
All new cases of coeliac disease or dermatitis herpetiformis.
Crude incidence rates (per quinquennia) for both children and adults. Age, sex, family history, symptoms at the time of diagnosis and time to diagnosis from symptom onset.
In total, 137 cases of coeliac disease (27 children, 110 adults) and 19 cases of dermatitis herpetiformis were detected. In adults with coeliac disease, incidence rates have risen from 1.32 to 3.08 per 100,000 with a 3:1 female predominance. Almost 50% of adults were over fifty years old when diagnosed and 25% had no abdominal symptoms. In children, the disease incidence has remained stable but with a rising trend in mean age at diagnosis and higher likelihood of atypical symptoms in older children. There has been no change in the incidence of dermatitis herpetiformis. Only 8.3% of all patients had an affected first-degree relative.
In contrast to other reports of declining incidence, coeliac disease in children has remained constant in South Glamorgan, but has markedly increased in adults, particularly women. Presentation may be at any age, often with atypical symptoms, which may delay diagnosis.
Irritable bowel syndrome has a high prevalence. Consensus diagnostic criteria (ROME II) based on symptoms have been established to aid diagnosis. Although coeliac disease can be misdiagnosed as irritable bowel syndrome, no prospective study has been published in which patients with this disorder are investigated for coeliac disease. We aimed to assess the association of coeliac disease with irritable bowel syndrome in patients fulfilling ROME II criteria.
We undertook a case-control study at a university hospital. 300 consecutive new patients who fulfilled Rome II criteria for irritable bowel syndrome, and 300 healthy controls (age and sex matched) were investigated for coeliac disease by analysis of serum IgA antigliadin, IgG antigliadin, and endomysial antibodies (EMA). Patients and controls with positive antibody results were offered duodenal biopsy to confirm the possibility of coeliac disease.
66 patients with irritable bowel syndrome had positive antibody results, of whom 14 had coeliac disease (11 EMA positive, three EMA negative). Nine patients with positive antibody results were lost to follow-up or refused biopsy (only one EMA-positive patient refused biopsy), and 43 had normal duodenal mucosa. Two controls, both of whom were EMA positive, had coeliac disease. Compared with matched controls, irritable bowel syndrome was significantly associated with coeliac disease (p=0.004, odds ratio=7.0 [95% CI 1.7-28.0]).
Patients with irritable bowel syndrome referred to secondary care should be investigated routinely for coeliac disease. With only EMA, three of 14 cases would have been missed.
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