R. Gillberg

Evaluation of gliadin antibodies for detection of coeliac disease.

To evaluate assay of gliadin antibodies of different immunoglobulin classes as a test for detection of coeliac disease, we analysed sera from 36 adult patients and 8 children with coeliac disease, 62 patients with other gastrointestinal diseases, and 124 blood donors with diffusion-in-gel enzyme-linked immunosorbent assay (DIG-ELISA). Depending on the choice of reference levels for gliadin antibodies of the IgA and IgG classes, respectively, we found a diagnostic sensitivity for coeliac disease of 93-86% and a diagnostic specificity of 95-100%. Determination of gliadin antibodies by DIG-ELISA can thus be used as a test for detection of coeliac disease and selection of patients for small-intestinal biopsy.

Upper gastrointestinal and mental symptoms in the irritable bowel syndrome.

Gastrointestinal and mental symptoms were assessed in 101 outpatients with the irritable bowel syndrome (IBS). A normal female population was used for comparison of mental symptoms. By definition all patients had abdominal pains and/or change of bowel habits (constipation or diarrhoea, or both) but no demonstrable organic disease. Upper gastrointestinal symptoms without peptic ulcer disease were reported by 87% of the patients. Mental symptoms were reported by almost all patients. Symptoms of anxiety, fatiguability, hostile feelings, sadness, and sleep disturbances were seen significantly more often among IBS women than in the controls. We conclude that patients with IBS frequently have upper gastrointestinal and mental symptoms that should be taken into account in the therapeutic management and evaluation of new modes of treatment.

Serum antibodies to gliadin in coeliac disease after gluten withdrawal.

Serum gliadin antibodies of the IgA and IgG classes were determined by the diffusion-in-gel enzyme-linked immunosorbent assay (DIG-ELISA) in 10 adult patients with villous atrophy of the small-intestinal mucosa. After introduction of a gluten-free diet a gradual decrease in serum gliadin antibody levels occurred, reaching statistical significance at 3 months of treatment for the IgA class (p less than 0.01) and at 6 months for the IgG class (p less than 0.05). A decrease of serum gliadin antibody levels after gluten withdrawal was related to an improvement of the intestinal mucosa and should thus be indicative of whether the patient is following the dietary recommendations. However, determination of gliadin antibody levels cannot replace small-intestinal biopsy, as there are a few patients in whom the antibody levels are not related to the morphology of the gut mucosa.

Chronic Inflammatory Bowel Disease in Patients with Coeliac Disease

Six patients with coeliac disease and inflammatory bowel disease are described. Of special interest were two patients with coeliac disease and dermatitis herpetiformis and ulcerative colitis, one of whom also had sclerosing cholangitis. Three patients had both coeliac disease and ulcerative colitis, and one of them also had sclerosing cholangitis. In one patient with coeliac disease Crohns disease of the small bowel was diagnosed. There seems to be association between coeliac disease without dermatitis herpetiformis, and ulcerative colitis. The possible combination of coeliac disease and inflammatory bowel disease deserves more attention than it has hitherto received.

Gastric Morphology and Function in Dermatitis Herpetiformis and in Coeliac Disease

Gastric acid secretory capacity was evaluated in 116 patients with dermatitis herpetiformis by means of the pentagastrin test. Endoscopic gastric mucosal biopsy specimens were obtained from both the body and the antrum in 90 of them. Forty-eight patients (41%) had a maximal acid output less than 10 mmol/h, and 30 of them (26%) were achlorhydric. The frequency of achlorhydria increased with age, and 27 out of 58 patients (47%) more than 50 years old were achlorhydric. Antrum-sparing chronic atrophic gastritis was present in 92% of the achlorhydric patients, and hypergastrinaemia and serum parietal cell antibodies were found in most of them. The prevalence of chronic gastritis of the body and of the antrum increased with age. There was no correlation between atrophic gastritis or achlorhydria and small-intestinal villous atrophy, the results of the D-xylose test, and blood folate and serum zinc determinations. The transferrin saturation index was lower in patients with achlorhydria. The frequency of achlorhydria was significantly higher in patients with dermatitis herpetiformis than in 69 patients with coeliac disease.

Endoscopic Duodenal Biopsy Compared with Biopsy with the Watson Capsule from the Upper Jejunum in Patients with Dermatitis Herpetiformis

Forty-eight patients with dermatitis herpetiformis were investigated with duodenoscopy, endoscopic biopsy, and conventional upper jejunal biopsy. Three endoscopic biopsy specimens were obtained from the duodenal bulb, three to six specimens from the second part of the duodenum, and one suction biopsy from the upper jejunum. In 60%, 71%, and 65% of the patients subtotal or partial villous atrophy was found in biopsies from the three levels, respectively. In eight patients (17%) mucosal abnormalities were confined to the duodenal biopsies and in two patients to the jejunal biopsies. The technique of endoscopic biopsy is advocated because multiple visually selected duodenal specimens may be obtained and because this technique also enables a complete evaluation of the stomach.

Hydrogen (H2) Breath Test and Gastric Bacteria in Acid-Secreting Subjects and in Achlorhydric and Postgastrectomy Patients before and after Antimicrobial Treatment

Sixteen patients with pentagastrin-fast achlorhydria and 12 patients who had undergone Billroth II gastrectomy (at least 3 years previously) were compared with 10 acid-secreting volunteers and 13 patients with endoscopically proven peptic disease. The concentration and type of gastric bacteria were analysed in achlorhydrics, Billroth II patients, and patients with peptic disease. A 6-h hydrogen (H2) breath test after a standardized meal was performed in all subjects. The mean concentration of gastric bacteria was significantly higher in achlorhydrics and Billroth II patients than in patients with peptic disease. End-expiratory H2 excretion was elevated in achlorhydrics and Billroth II patients to levels significantly exceeding those of acid-secreting volunteers and patients with peptic disease. In achlorhydrics, total bacterial concentration in gastric juice was correlated to H2 excretion between 60 and 180 min after the meal. Treatment of achlorhydric and postgastrectomy patients with trimethoprim/sulphamethoxazole lowered H2 breath concentrations in both groups and reduced symptoms in achlorhydrics. Elevated end-expiratory H2 levels after a test meal indicate upper gastrointestinal bacterial overgrowth in achlorhydrics and in postgastrectomy patients.

Symptom Profiles in Chronic Peptic Ulcer Disease

Abdominal and mental symptoms were assessed in 103 outpatients with chronic peptic ulcer disease. Patients with present symptoms and a history of duodenal or prepyloric ulcer were included if they had no other disorder requiring treatment. A normal female population was used for comparison of mental symptoms. Besides the cardinal ulcer or acid-related symptoms, there was a high rate of indigestion and bowel dysfunction symptoms, usually associated with the irritable bowel syndrome. Mental symptoms were reported by almost all patients. Symptoms of anxiety, depression, and neurasthenia were seen significantly more often among the female patients than in the normal women. We conclude that a wide range of both abdominal and mental symptoms should be taken into account in the therapeutic management of peptic ulcer disease, in evaluation of clinical trials, and in studies of the natural history.

Secretin release in coeliac disease. Plasma secretin concentration and bicarbonate output to the duodenum after intraduodenal acid infusion in coeliac patients before and after treatment.

Infusion of 40 ml 0.1 mol/l HCl into the duodenum in eight untreated coeliac patients was followed by an increase of the plasma immunoreactive secretin (IRS) concentration from 1.6 +/- 0.2 pmol/l to a peak level of 2.4 +/- 0.3 pmol/l (p less than 0.05). After treatment with a gluten-free diet, the same patients showed an increase from 1.4 +/- 0.3 pmol/l to a peak level of 5.5 +/- 0.9 pmol/l after intraduodenal acid infusion, which was significantly higher than before treatment (p less than 0.01). In control subjects, intraduodenal acid infusion was followed by an increase from 1.4 +/- 0.2 pmol/l to 6.7 +/- 1.1 pmol/l, which was significantly higher than in untreated coeliac disease (p less than 0.01) but did not differ from what was found in treated coeliac patients. Significant differences in pH, volume, or bicarbonate content of the duodenal aspirates or the basal IRS levels were not found.

Influence of Gluten-Free Diet on the Gastric Condition in Dermatitis Herpetiformis

Achlorhydric atrophic gastritis occurs in approximately 25% of patients with dermatitis herpetiformis (DH). The effect of gluten withdrawal on the gastric condition was studied in 35 patients, with a control group of 20 patients continuing their habitual diet. Gastrointestinal examinations were performed initially and repeated after about 1 3/4 years. Adherence to the diet was confirmed by dietary interviews, improvement of malabsorption test results and intestinal villous structure, and decreased dapsone requirement. Neither the non-restricted diet nor the gluten-free diet had any effect on gastric morphology, the ability to secrete gastric acid, serum gastrin levels, or the frequency or titres of circulating parietal cell antibodies. The findings indicate that gluten is not responsible for the perpetuation of the gastric affection in DH, in contrast to the enteropathy.