Michael L. Clark

Amino acid and peptide absorption in patients with coeliac disease and dermatitis herpetiformis

A double-lumen perfusion technique has been used to study amino acid and peptide absorption in eight normal control subjects, 13 patients with untreated adult coeliac disease, and 16 patients with dermatitis herpetiformis who had varying morphological abnormalities of the small bowel. All subjects were perfused with isotonic solutions containing 10 mM glycyl-L-alanine and 10 mM glycine + 10 mM L-alanine. Patients with adult coeliac disease had impaired absorption of glycine (p < 0·01) and L-alanine (p < 0·05) from the amino acid solution compared with the control subjects. Amino acid uptake from the dipeptide solution was not significantly impaired, although four individual patients had impaired uptake of both amino acids. In contrast to these findings, very few patients with dermatitis herpetiformis had impaired amino acid absorption from either solution. Sodium absorption was impaired from both solutions when the groups of patients with adult coeliac disease and dermatitis herpetiformis with subtotal villous atrophy and partial villous atrophy were studied, and there were patients in each group who secreted sodium and water. The results suggest that malabsorption of dietary protein is unlikely to occur in dermatitis herpetiformis but may occur and contribute to protein deficiency seen in some severe cases of adult coeliac disease. The impairment of sodium and water absorption provides evidence that there may be functional impairment of the jejunal mucosa in dermatitis herpetiformis as well as in adult coeliac disease.

Jejunal mucosal immunoglobulin-containing cells and jejunal fluid immunoglobulins in adult coeliac disease and dermatitis herpetiformis

Immunoglobulin-containing plasma cell densities in the jejunal mucosa and serum and jejunal fluid immunoglobulins have been measured in patients with adult coeliac disease and dermatitis herpetiformis with and without jejunal mucosal abnormality. Studies were performed in patients before and after treatment of the jejunal lesion. Total immunofluorescent plasma cells were increased in untreated adult coeliac disease and dermatitis herpetiformis patients with jejunal lesions, but in general the normal predominance of IgA > IgM > IgG was found. There was no difference from controls in IgA-containing cells in the two conditions before or after treatment. The numbers of IgM-containing cells were significantly increased both before and after treatment in groups of patients with adult coeliac disease and dermatitis herpetiformis who had jejunal lesions. IgG-containing cells were significantly raised in only the before-treatment groups. Patients with dermatitis herpetiformis without jejunal lesions, even whilst on gluten-containing diets, had normal numbers of immunoglobulin-containing cells. IgA and IgM jejunal fluid immunoglobulins were significantly raised in dermatitis herpetiformis and adult coeliac disease. It is concluded that patients with dermatitis herpetiformis with jejunal morphological abnormality have a comparable immunological disturbance of the jejunal mucosa to that found in adult coeliac disease.

Antireticulin antibodies in dermatitis herpetiformis and adult coeliac disease

Antireticulin antibody was present in 17% of sera from thirty‐five patients with dermatitis herpetiformis, 45% from twenty‐eight patients with adult coeliac disease and none of thirty healthy controls.

Treatment of dermatitis herpetiformis with corticosteroids and a gluten-free diet: a study of jejunal morphology and function

The jejunal morphological and functional response to either a gluten-free diet or corticosteroid therapy was studied in six patients with dermatitis herpetiformis. In each treatment group there were two patients with subtotal villous atrophy and one with partial villous atrophys. After treatment, in both groups, morphological improvement was seen in villous and surface cell heights, mucosal thickness, and intraepithelial lymphocyte counts. Jejunal function was assessed using the perfusion technique. Absorption of glucose from a 56 mM solution was shown to improve. Water movement from this solution was in a secretory state in four patients (two in each group) before treatment and moved into the normal absorptive range after treatment. These results further outline the similarity between the mucosal lesion of dermatitis herpetiformis and true coeliac disease.