Mauriño E

Risk of fractures in celiac disease patients: a cross-sectional, case-control study

OBJECTIVES:Although osteopenia and osteoporosis are well-recognized complications of celiac disease, no controlled studies have been done to assess the prevalence of fractures in a large cohort of patients. The objectives of this study were to determine the prevalence of bone fractures and vertebral deformities in celiacs and to analyze the relationship between fractures and clinical data of patients.METHODS:We studied 165 patients with a well-established diagnosis of celiac disease. A similar number of age- and gender-matched control subjects with functional GI disorders were evaluated. The design of the study was cross-sectional, with a retrospective historical review through a personal interview of all subjects. All patients underwent bone mineral density measurement by dual-energy, x-ray absorptiometry and spinal x-ray. Vertebral deformities were determined by visual inspection of spinal x-rays and by morphometric analysis.RESULTS:Among celiacs, 41 patients (25%) referred have had from one to five fractures in the peripheral skeleton. On the contrary, only 14 (8%) control subjects experienced fractures. This difference was highly significant (odds ratio, 3.5; 95% confidence interval [CI], 1.8–7.2; p < 0.0001). Although inspection of spinal x-rays showed evidence of vertebral deformities in the lumbar spine in only two patients, a more detailed examination of lateral x-rays using morphometric criteria detected lumbar spine vertebral deformities in nine (five also had fractures in the peripheral skeleton) and in four controls (odds ratio, 2.8; 95% CI, 0.7–11.5; p = NS). Eighty percent of fractures were detected before the diagnosis of celiac disease or in patients who were noncompliant with the gluten-free diet; only 7% of patients experienced fractures after starting treatment. Regression analysis adjusted for multiple comparisons showed that patients with fractures were diagnosed with celiac disease later (p < 0.06) and remained undiagnosed for more prolonged periods (p < 0.05). There was a trend, which did not reach statistical significance, for a lower bone mineral density in the lumbar spine and total skeleton among patients with fractures.CONCLUSIONS:This study has demonstrated that patients with celiac disease had a high prevalence of bone fractures in the peripheral skeleton. Most of these events occurred before diagnosis or while patients were noncompliant with gluten-containing diet. Our results suggest that early diagnosis and effective treatment of celiac disease were the most relevant measures to protect patients from the risk of fractures.

Pre- and post-treatment serum levels of cytokines IL-1β, IL-6, and IL-1 receptor antagonist in celiac disease. Are they related to the associated osteopenia?

Objective:Decreased bone mineral density is a common finding in untreated celiac disease patients. However, the precise pathophysiology of osteopenia remains incompletely understood. Pathological features of gluten sensitivity are associated with local release of proinflammatory and antiinflammatory cytokines. We investigated the serum levels of IL-1β, IL-6, and IL-1 receptor antagonist in celiac patients and correlated them with bone density measurements.Methods:We assessed serum samples of 16 female patients at the time of diagnosis (on an unrestricted diet) and after a mean time of 37 months on a gluten-free diet. At the same time, bone mineral density in the lumbar spine and total skeleton was determined by DEXA.Results:Untreated patients had high serum levels of IL-1β and IL-6 and normal IL-1-RA. Treatment produced a decrease in median IL-1β levels (p = NS) and a significant diminution of IL-6 (p < 0.05). On the contrary, IL-1-RA increased significantly after treatment (p < 0.05). Baseline lumbar spine Z-score and IL-6 levels exhibited a significant inverse correlation (r =–0.61; p < 0.01). Patients with more severe baseline osteopenia (< -2 Z-scores) had a significantly lower IL-1-RA than those with less bone compromise (> -2 Z-scores).Conclusions:Our data demonstrate that the inflammatory process observed in active celiac disease is associated with high serum levels of IL-1β and IL-6 and normal levels of IL-1-RA. Treatment significantly reduces both proinflammatory cytokines and significantly increases the antiinflammatory one. We also suggest that these cytokines might have a role in the osteopenia associated with celiac disease.

The administration of gliadin downregulates the intraepithelial lymphocytosis induced by a rectal gluten challenge.

slight elevation of ALAT around 40 U/L. The viral load 12 wk postinfusion was 3.7 10 copies/ml and 3.3 10 copies/ml after 9 months and thus lower compared with the initial evaluation. The second patient was a 32-yr-old white man with CD since 1981, subtotal colectomy as a result of a sigma perforation with peritonitis in 1988, subsequent definite ileostoma because of relapsing anastomositis with presacral fistulas, and a perianal exstirpation of the rectum because of recurrent perianal fistulas in 1994. Incidentally, a hepatitis C, serotype 1, was diagnosed without biochemical signs of inflammation of the liver. An extensive evaluation of the liver was performed in 1995 because of a biochemically low-grade cholestasis measuring ALP 467 U/L, -glutaryl transferase 147 U/L, ASAT 19 U/L, ALAT 70 U/L, total bilirubin 2.6 mg/dl, and direct bilirubin 1.5 mg/dl. Liver biopsy revealed a low-grade toxic liver damage, but no signs of viral hepatitis. A primary sclerosing cholangitis was ruled out by laboratory testing and an endoscopic retrograde cholangiography. The cholestasis was eventually explained as a toxic liver damage caused by p.o. cephalosporin. Relapsing severely secreting perinal fistulas confirmed by magnetic resonance tomography were treated with azathioprine 100 mg successfully, but this treatment had to be discontinued because of subjective intolerance in 1998. In June 2000, a new perianal fistula with prurulent secretion occurred, and magnetic resonance tomography revealed a liquid retention of 10-mm diameter in the left ischiorectal fossa with a cutaneous fistula to the perianal region. With regard to the severe fistulas in the past, we decided to treat the patient with infliximab. At this point, there were no biochemical signs of active hepatitis, and the viral load was 3.6 10 copies/ml. The patient was given a single infusion of 5 mg/kg of body weight, which was tolerated well. The cutaneous fistula disappeared after 2 wk, and no relapse has occurred during the follow-up of 18 months. The liver values were monitored at wk 1, 3, 6, and 9 and after 6, 9, and 12 months and were within normal ranges. The viral load after 6 wk and 12 months was not elevated with 2.5 10 copies/ml. These cases are important clinical observations. They suggest that infliximab can be used as a potent therapeutic option in refractory cases of CD despite the presence of chronic hepatitis C, even though further studies are warranted.

Letter to the editorThe administration of gliadin downregulates the intraepithelial lymphocytosis induced by a rectal gluten challenge

The Administration of Gliadin Downregulates the Intraepithelial Lymphocytosis Induced by a Rectal Gluten Challenge