Cjj Mulder

Survival in Refractory Coeliac Disease and Enteropathy associated T cell Lymphoma: Retrospective evaluation of single centre experience

Background: Coeliac disease may be regarded as refractory disease (RCD) when symptoms persist or recur despite strict adherence to a gluten-free diet. RCD may be subdivided into types I and II with a phenotypically normal and aberrant intraepithelial T-cell population, respectively. RCD I seems to respond well to azathioprine/prednisone therapy. RCD II is usually resistant to any known therapy and transition into enteropathy-associated T-cell lymphoma (EATL) is common. Aim: To provide further insight into RCD and the development of EATL, by reporting on long-term survival and risk of transition of RCD into EATL in a large cohort of patients with complicated coeliac disease. Design and Methods: Retrospective comparison of responses to therapy in four groups of patients with complicated coeliac disease: 43, RCD I; 50, RCD II (total), of whom 26 with RCD II developed EATL after a period of refractoriness to a gluten-free diet (secondary EATL) and 13 were EATL patients without preceding history of complicated coeliac disease (de novo EATL). Results: No coeliac-disease-related mortality was recognised in the RCD I group. The overall 5-year survival in the RCD I group it was 96%; in the RCD II (total) group was 58%; and in the RCD II group after developing EATL it was only 8%. The 2-year survival in the de novo EATL group was 20% versus 15% in secondary EATL group (p = 0.63). Twenty-eight (56%) of the 50 patients with RCD II died, 23 (46%) due to EATL, 4 due to a progressive refractory state with emaciation and 1 from neurocoeliac disease. Conclusion: Remarkably, no patient with RCD I developed RCD II or EATL within the mean follow-up period of 5 years (range 2–15 years). A total of 52% of the RCD II patients developed EATL within 4–6 years after the diagnosis of RCD II. More aggressive and targeted therapies seem necessary in RCD II and EATL.

Accuracy of Serologic Tests and HLA-DQ Typing for Diagnosing Celiac Disease

Context The value of adding HLA genetic typing to serologic testing for celiac disease is not well defined. Contribution In this prospective study of patients referred for evaluation of celiac disease, the test performance of combinations of genetic typing and serologic testing was similar to that of either strategy alone. Caution The small number of cases of celiac disease precluded meaningful comparisons of testing strategies. Implications The combination of genetic typing and serologic testing is about as accurate as either strategy alone. Neither is a substitute for small-bowel biopsy in the diagnosis of celiac disease. The Editors The high prevalence and clinical heterogeneity of celiac disease necessitate noninvasive tests for diagnosis. Specifically, tests are needed to select which patients should undergo small-bowel biopsy. Although celiac disease serologic tests, especially IgA tissue antitransglutaminase antibodies (TGA) and IgA antiendomysium antibodies (EMA), are often used for this purpose because of their reported high sensitivity (1), they may perform less well in the clinical setting (2). Most studies have not defined the usefulness of serologic tests prospectively (37), and in addition, some authors doubt the high sensitivity of these tests (8, 9). Susceptibility to celiac disease is related to the presence of distinct HLA-DQ heterodimersthe DQ2 heterodimer encoded by the alleles HLA-DQA1*05 and HLA-DQB1*02, and the DQ8 heterodimer encoded by the alleles HLA-DQA1*03 and HLA-DQB1*0302 (1014). One way to improve the selection of patients to undergo small-bowel biopsy may be to combine serologic tests with HLA-DQ typing (15, 16). We designed a prospective study to define the value of specific serologic tests, HLA-DQ typing, or both in diagnosing celiac disease. Methods The institutional review board of the VU University Medical Center, Amsterdam, the Netherlands, approved the study protocol. All participants received oral and written information according to the usual recommendations for medical research and the Declaration of Helsinki (17) and gave written informed consent. Patients The study was performed in an academic, mixed secondary and tertiary referral center that serves a population of about 200000 people. In the design phase of the study (19992000), the staff of departments of internal medicine and gastroenterology reviewed the literature and agreed that serologic tests could not substitute for small-bowel biopsy in the diagnostic work-up of celiac disease. Therefore, the policy was to perform small-bowel biopsy when celiac disease was suspected. Adults suspected of having celiac disease who were attending the endoscopy department for small-bowel biopsy were requested to give blood samples for serum antibody testing and HLA-DQ typing. We excluded patients younger than 18 years of age, those with known celiac disease, and patients who declined to undergo endoscopy. Endoscopy We performed upper gastrointestinal endoscopy with Olympus video endoscopes (GIF-NT140/160, Olympus Nederland, Zoeterwoude, the Netherlands) and obtained 4 oriented biopsy specimens from the distal duodenum (18). Serum Antibody Tests We performed serologic tests after obtaining small-bowel biopsy specimens in all patients to avoid referral bias. All serologic tests were determined anonymously without knowledge of the clinical status or histologic result. We determined IgA and IgG antigliadin antibodies (AGA-IgA and AGA-IgG, respectively) by using enzyme-linked immunosorbent assay (ELISA). We tested for EMA according to the method of Lerner and colleagues (19) by indirect immunofluorescence assay using monkey esophagus (16). Finally, TGA was determined by ELISA, essentially as described by Dieterich and colleagues (20), with guinea pig TGA (gp-TGA) (Sigma-Aldrich, Poole, United Kingdom; coating 10 g/mL in Tris hydrochloride [pH, 7.5] with 5-mmol/L of CaCl2) as the substrate (20). Sera were diluted and preincubated (30 minutes at room temperature) with 1% bovine serum albumin to avoid nonspecific binding (16, 21). The cutoff values for the titers of AGA and gp-TGA tests are based on measurements in control groups (blood donors, patients without celiac disease, and the general population age 2 to 4 years), and optimization was done by a receiver-operating characteristic curve analysis in well-defined patient groups. Because the recombinant human TGA (rh-TGA) assay became available when the study was already ongoing, we retrospectively reevaluated all samples from patients with an abnormal result on serologic testing or histologic examination by using rh-TGA as substrate (Roboscreen, Leipzig, Germany; coating 5 g/mL and same conditions as those for gp-TGA). When serologic test results did not match histologic findings, we measured total serum IgA and repeated the serologic tests. In cases of IgA deficiency, we evaluated TGA-IgG antibodies. We defined seropositivity as 1 or more positive measured antibody test results and seronegativity as negative results on all 4 tests. HLA-DQ Typing Whole blood was obtained for HLA-DQA1 and HLA-DQB1 genotyping. Polymerase chain reactionamplified exon 2 amplicons were generated for low- to medium-resolution typing in a combined, single-stranded conformation polymorphismheteroduplex assay by a semiautomated electrophoresis and gel-staining method on the PhastSystem (Amersham Pharmacia Biotech, Uppsala, Sweden). Alleles DQA1*05 and DQB1*02 (encoding the HLA-DQ2 heterodimer) and alleles DQA1*03 and DQB1*0302 (encoding the HLA-DQ8 heterodimer) could be reliably characterized in homozygous and heterozygous states. This method has been validated by using a panel of reference DNA against the Dynall Allset sequence-specific primers high-resolution typing kits (Dynal A.S., Oslo, Norway) (16, 22). Histologic Studies A gastrointestinal pathologist who was masked to clinical data evaluated the biopsy material, and an independent pathologist reviewed the samples when histologic examination was abnormal. Consensus was reached on the final diagnosis. Villous (crypt) anatomy and density of intraepithelial lymphocytes were assessed uniformly by using hematoxylineosin and immunohistologic anti-CD3 staining, respectively. Appendix Figures 1 and 2 show the histologic grading of abnormalities, based on the most severe change found according to the modified Marsh classification (23, 24). Appendix Figure 1. Small-bowel histologic findings (Marsh 0 to II). A. B. C. Appendix Figure 2. Small-bowel histologic findings (Marsh IIIa to IIIc). A. B. C. Diagnosis and Follow-up of Celiac Disease The diagnosis of celiac disease was based on the European Society for Paediatric Gastroenterology, Hepatology and Nutrition criteria, revised in 1989 and published in 1990, by identifying characteristic histologic findings (Marsh III) on small-bowel biopsy and unequivocal clinical resolution after a gluten-free diet was initiated (25). Thus, by this definition and for this study, the diagnosis of celiac disease did not require follow-up biopsy. However, we assessed histologic response in most patients and serologic response in all patients who were found to have celiac disease. We defined a serologic response as the disappearance of initially positive celiac disease antibody test results and histologic response as the regression of villi to Marsh 0 to II on a repeated biopsy at least 12 months after a gluten-free diet was initiated (24). Statistical Analysis We compared results of serologic tests and HLA-DQ typing with the diagnosis of celiac disease as previously defined. We performed statistical analysis by using SPSS software, version 11.0 (SPSS, Chicago, Illinois). To calculate exact binomial CIs, we used StatXact software, version 7.0.0 (Cytel Software, Cambridge, Massachusetts). We used 2 2 tables (Bayes theorem) to calculate sensitivities and specificities, predictive values, and likelihood ratios. We used the t test and Fisher exact test to compare continuous data and categorical data, respectively. We calculated posttest probabilities (and CIs) of celiac disease for different diagnostic tests or a combination thereof by using the method recommended by Altman (26). Role of the Funding Source The study received no funding. Results Patients Between January 2001 and January 2004, 502 consecutive patients (originally from community practices in the Amsterdam area) were referred from outpatient internal medicine and gastroenterology clinics for endoscopy and small-bowel biopsy for the diagnosis of celiac disease. Another 16 inpatients were referred from the internal medicine and gastroenterology inpatient wards. No referred patient was under the care of the investigators. We excluded 55 (10.6%) patients because they declined to participate in the study after the small-bowel biopsy. Age, sex, body mass index, ethnicity, and indications for referral did not statistically significantly differ between those included in and those excluded from the study (data not shown). The available serologic data (n = 20), HLA-DQ data (n = 4), and histologic examinations (n = 55) suggested the absence of celiac disease in excluded patients. Therefore, 463 patients were included in the study: 346 (75%) were unrelated Dutch Caucasian persons and 117 (25%) were not Caucasian (Indian, Chinese, North African [Arab], and Central African [black], in descending order of frequency). All patients were on a normal diet at the time of inclusion. Table 1 summarizes the general characteristics and indications for small-bowel biopsy of patients without and with celiac disease. Table 1. Characteristics of and Indications for Referral in Patients without and with Celiac Disease Patients with Celiac Disease Of the 463 patients enrolled, 16 (3.46% [95% CI, 1.99% to 5.55%]) fulfilled the diagnostic criteria for celiac disease (Figure) (25) within a median follow-up interval of 22 months (range, 11 to 44 months). Biopsy readings of the 2 pathologists were concor

The daily gluten intake in relatives of patients with coeliac disease compared with that of the general Dutch population

Background: It has been suggested that the amount of gluten intake in populations offers an explanation for differences in the epidemiology of coeliac disease. Investigations into first‐degree relatives of coeliac disease patients have often shown that relatives exhibit intermediate features of coeliac disease, possibly due to a low gluten intake. Aims: The aim of this study was to investigate the pattern of gluten consumption in the general Dutch population for different age and sex groups and for different product groups, and to investigate the daily gluten intake of first‐degree relatives of coeliac disease patients. Methods: Questionnaires concerning the gluten intake of 55 first‐degree relatives of coeliac disease patients were analysed. To determine the gluten intake of the general Dutch population, the results of a mass investigation were used. The amount of gluten in the gluten‐rich products was estimated by multiplying the amount of vegetable proteins by 0.8. Results: The median daily gluten intake of the relatives was 12.9g (range: 3.8‐31.3). The mean daily gluten intake of the study population in the Netherlands was 13.1 g. Conclusion: The gluten intake of first‐degree relatives of coeliac disease patients was the same as that of the general population. Thus, a low gluten intake apparently does not explain the aspecific presentation and prevalence of coeliac disease in firstdegree relatives of coeliac disease patients.

Clinical implications of the sugar absorption test: Intestinal permeability test to assess mucosal barrier function

BACKGROUND We wanted to investigate the influence of viral genotype on the severity of liver injury and response to interferon and whether the level of viremia differs in accordance with genotype, severity of liver disease, and response to interferon in patients with hepatitis C virus (HCV) infection. METHODS We studied 118 patients with HCV-related liver disease. HCV genotypes were determined with a line probe assay, and serum HCV RNA levels with a competitive reverse transcription polymerase chain reaction assay. RESULTS HCV type 1b was the most prevalent genotype (88%). It was present in 100% of cirrhotic patients, with or without hepatocellular carcinoma (HCC), but only in 78% of patients with chronic hepatitis (P < 0.001). The response to interferon was better in patients infected with non-1b HCV genotypes (P = 0.002). In a multivariate analysis non-1b HCV genotypes and a low hepatic fibrosis correlated with a favorable response to interferon. Among patients with chronic hepatitis those infected with HCV type 1b were older (P < 0.001), and age was the only independent factor associated with HCV type 1b. Viremia levels differed neither between genotypes nor in response to interferon and was significantly lower in patients with cirrhosis and HCC. CONCLUSIONS HCV 1b was associated with more severe liver disease and a worse response to interferon therapy. Non-1b genotypes and a lower liver fibrosis were the only independent predictors of a favorable response to interferon. Levels of HCV viremia differed neither among different genotypes nor in response to interferon and decreased with advanced liver disease.

A microarray screen for novel candidate genes in coeliac disease pathogenesis

Background and aims: The causative molecular pathways underlying the pathogenesis of coeliac disease are poorly understood. To unravel novel aspects of disease pathogenesis, we used microarrays to determine changes in gene expression of duodenal biopsies. Methods: cDNA microarrays representing 19 200 genes were used to compare gene expression profiles of duodenal biopsies from 15 coeliac disease patients with villous atrophy (Marsh III) and seven control individuals with normal biopsies (Marsh 0). In addition, the specific effect of gluten was studied by comparing the expression profiles of Marsh III lesions of seven patients exposed to gluten with four patients on a gluten free diet. Results: Comparing Marsh III with Marsh 0 lesions identified 109 genes that differed significantly (p<0.001) in expression levels between patients and controls. A large number of these genes have functions in proliferation and differentiation pathways and might be important for correct development of crypt-villous units. Alterations in these pathways may lead to the characteristic hyperplasia and villous atrophy seen in coeliac disease. The analyses also revealed 120 differentially expressed genes (p<0.005) when comparing patients on a gluten free diet with those exposed to gluten. These genes further strengthen our observation of increased cell proliferation in the presence of gluten. Conclusions: Our study provides new candidate genes in the pathogenesis of coeliac disease. Based on our results, we hypothesise that villous atrophy in coeliac disease patients is due to failure in cell differentiation. These genes are involved in pathways not previously implicated in coeliac disease pathogenesis and they may provide new targets for therapy.

Coeliac disease and (extra)intestinal T-cell lymphomas: definition, diagnosis and treatment

Intestinal lymphomas encompass those lymphomas with a dominant or only localized occurrence in the intestinal tract. Coeliac disease is highly associated with enteropathy-associated T-cell lymphomas (EATLs). Coeliac disease-related lymphomas can appear at nodal or extranodal sites. EATL is often multifocal with ulcerative lesions, which explains the high perforation rate at presentation or during chemotherapy. Staging includes ear-nose-throat examination and CT scan of the chest and abdomen. Positron emission tomography (PET) scanning may be valuable. Accurate diagnosis based on endoscopic biopsies is preferable; if necessary, full thickness laparoscopic small-bowel biopsies are mandatory. Refractory coeliac disease (RCD) with aberrant T cells carries a high risk of development of EATLs. There is no satisfactory treatment for EATL, the only possibility of preventing EATL development in RCD being autologous bone marrow transplantation. EATLs can present in 20% of patients as extra-small-bowel T-cell lymphomas; such as subcutaneous panniculitis-like lymphoma, hepatosplenic γ/δ lymphoma, nodal as well as sinus, gastric or colon disease and extraintestinal T-cell lymphomas. The majority of EATLs present as large cell lymphoma CD[Formula: See Text] [Formula: See Text], CD[Formula: See Text] [Formula: See Text], CD[Formula: See Text] [Formula: See Text]; however, they also present as small cell lymphoma CD[Formula: See Text] [Formula: See Text], CD[Formula: See Text] [Formula: See Text], CD[Formula: See Text] [Formula: See Text]. Sometimes γ/δ lymphomas in CD are recognized. Work-up of EATL must include immunohistology, T-cell flow cytometry, T-cell rearrangement and adequate imaging with CT and PET scanning.

SAT and serology in adult coeliacs, seronegative coeliac disease seems a reality

UNLABELLED The aim of this study was to assess the correlation of sugar absorption test (SAT) using Lactulose/Mannitol/Sucrose (LMS), with IgA-endomysium (EMA), and IgA-gliadin (AGA) antibodies in relation to the severity of the intestinal mucosal damage in adult coeliacs. We have differentiated the Marsh classification in partial villous atrophy (VA) (III a), subtotal VA (III b), and total VA (III c). Twenty-nine untreated adults coeliacs, with a mean age of 47 years, range 20-76 yrs were studied over 3 years. SAT, IgA-AGA and IgA EMA were performed in 29 consecutive coeliac patients with villous atrophy on a gluten containing diets. RESULTS Histopathological evaluation of small intestinal mucosa showed a partial VA in 14/29, subtotal VA in 10/29 and total VA in 5/29. All coeliacs with total VA had positive EMA (5/5 100%). However in coeliacs with partial VA sensitivity of EMA was poor (4/14 29%). Sensitivity of EMA in patients with subtotal VA was 50% (5/10). AGA was raised in 3/14 (21%), 6/10 (60%), and in 4/5 (80%) coeliacs with partial, subtotal and total VA respectively. AGA was raised in 13/29 (sensitivity 45%). SAT was abnormal in 26/29 (sensitivity: 89%). One patient had abnormal SAT, EMA and AGA. Eleven of 29 patients (38%) were negative for AGA and EMA, but SAT was abnormal in 10 of them. One patient was positive for EMA, negative for AGA, normal for SAT. EMA and/or AGA were positive in 18/29 (sensitivity 62%). Our study suggests that negative predictive value of serology should be interpreted cautiously since coeliacs with partial VA are negative in serology. Over the last ten years SAT and EMA have been accepted as screening tools for CD. SAT seems to be more sensitive than serology. However there is no standardized agreement in the literature for serology and SAT. A combination of SAT and serology may provide a good sensitivity in order to detect that subgroup of coeliacs with milder histopathological abnormality.

Long‐term lansoprazole treatment for gastro‐oesophageal reflux disease: clinical efficacy and influence on gastric mucosa

Long‐term acid suppression is believed to accelerate atrophic gastritis in Helicobacter pylori‐positive patients. The influence of long‐term therapy with lansoprazole has not been examined.

Intestinal permeability in exocrine pancreatic insufficiency due to cystic fibrosis or chronic pancreatitis

Disturbances of the intestinal integrity, reflected by an increased intestinal permeability, are reported in cystic fibrosis (CF). Controversy exists whether the increased intestinal permeability is due to CF itself or a consequence of the concomitant exocrine pancreatic insufficiency (PI). We measured intestinal permeability by the sugar absorption test in 32 PI patients: 20 CF-PI, 12 nonCF-PI with chronic pancreatitis, and 50 controls. In the sugar absorption test, the lactulose/mannitol ratio is measured in 5-h urine samples after oral ingestion of a solution of lactulose and mannitol, hypersmolar by the addition of sucrose. The lactulose/mannitol ratio was increased in both CF-PI and nonCF-PI versus controls (p< 0.0001). In CF, the L/M ratio and permeability for lactulose and mannitol did not change by increasing pancreatic enzyme supplementation by 30-50% for 2 wk (p = 0.74, p = 0.97, p = 0.74, respectively) nor by decreasing the osmolarity of the test solution by 75% (p = 0.24, p = 0.10, p = 0.39, respectively). We conclude that an increased intestinal permeability in CF is probably a consequence of PI and is not related to the dose of pancreatic enzyme supplementation nor the osmolarity of the test solution. The increase is due to an increased permeability for lactulose which might point toward a defect in the tight junctions of the villi and/or crypts. The cause of the increased intestinal permeability in the presence of PI is still unclear. An increased intestinal permeability points toward an impaired functional integrity of the small bowel, which may contribute to gastrointestinal dysfunction in CF.

Aberrant T-lymphocytes in refractory coeliac disease are not strictly confined to a small intestinal intraepithelial localization†

Refractory coeliac disease (RCD) is characterized by persisting mucosal pathology in spite of a strict gluten free diet (GFD). In RCD type II, phenotypically aberrant (CD7+CD3‐CD4/8‐cytoplasmicCD3+) T‐lymphocytes are present within the intraepitelial lymphocyte (IEL) population in the small intestine, and 50–60% of these patients develops an enteropathy associated T‐cell lymphoma (EATL).