Previous misdiagnosis and diagnostic delay in adult celiac sprue.
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Adult↗
Biomedical subjects
G R Corazza
Publications and source records attributed to G R Corazza.
Doppler ultrasonographic evaluation of splanchnic blood flow in coeliac disease.
BACKGROUND: Current knowledge on splanchnic haemodynamics in coeliac disease is limited and incomplete. AIM: To evaluate splanchnic arterial and venous blood flow in coeliac disease. METHODS: In 22 coeliac (13 untreated, nine treated) patients and in nine healthy subjects the following variables were assessed: vessel diameter and mean flow velocity in portal vein, splenic vein, superior mesenteric vein, and superior mesenteric artery. Peak systolic velocity, end diastolic velocity and pulsatility index were also determined in the superior mesenteric artery. Five patients of the untreated group were re-evaluated after nine months on a gluten free diet. RESULTS: Significant differences in haemodynamic variables between the three groups were shown only in the superior mesenteric artery. An increase in both mean flow velocity and end diastolic velocity and a reduction in pulsatility index occurred in untreated patients compared with treated patients (p < 0.002; p < 0.04; p < 0.035) and with healthy controls (p < 0.001; p < 0.025; p < 0.0003). Similar results were obtained for the five patients evaluated before and after treatment (p < 0.03; p < 0.02; p < 0.03), in whom the mean flow velocity in the superior mesenteric vein also decreased after treatment (p < 0.05). No significant differences were noted between treated coeliac patients and healthy controls. CONCLUSIONS: In untreated coeliac disease there is a hyperdynamic mesenteric circulation that decreases after treatment.
Adult↗
Osteopenia in adult coeliac disease.
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Adolescent↗
Estimating the incidence of coeliac disease with capture-recapture methods within four geographic areas in Italy.
STUDY OBJECTIVE: To estimate the incidence rate of newly diagnosed cases of coeliac disease in Italy. DESIGN: This was a descriptive study of coeliac disease incidence in the period 1990-91. SETTING: During 1990-91 newly diagnosed cases of coeliac disease were signalled by several sources including diagnostic records of departments of paediatrics, general medicine and gastroenterology, national health service records for the supply of gluten free diets and the archives of the Italian Coeliac Society. PATIENTS: Altogether 1475 cases were flagged throughout Italy, 478 of whom were selected, corresponding to 270 individual patients from a target population resident in four areas: Provices of Turin and Cuneo (Piedmont Region, northern Italy); Province of Brescia (Lombardia Region, northern Italy); Umbria Region (central Italy) and Sardinia Region (insular Italy). Only for these areas were patients flagged from several sources and the reference population was identifiable. MAIN RESULTS: The overall crude incidence rates for all ages per 100,000 residents per year were 2.4, 2.7, 1.5, and 1.7 in the four areas, respectively. The childhood cumulative incidence rates (aged < or = 15 years) per 100,000 live births were 143, 141, 72, and 80 respectively. The mean ages at diagnosis were similar for both childhood and adult cases throughout the areas--these were around 4 and 34 years respectively. For each area, the incidence rate was constantly higher in the main city than elsewhere. Using the capture-recapture method, an estimated completeness of case archives of 0.84 was obtained, whereas this figure was only 0.47 for hospital sources. CONCLUSIONS: This population based study on the incidence of coeliac disease shows that several information sources should be used to avoid underestimation. The incidence rate of coeliac disease in Italy was among the highest in Europe, and was widely variable showing highest figures in Piedmont and Lombardia and the lowest in Umbria and Sardinia. This trend was not due to different age at diagnosis, which suggests variable diagnostic awareness of the disease rather than different environmental patterns affecting the clinical presentation.
Adolescent↗
Clinical, pathological, and antibody pattern of latent celiac disease: report of three adult cases.
We report the clinical, pathological, and serological findings of three adult patients with latent celiac disease. The initial intestinal biopsies, which were normal, were carried out in the first case during an upper gastrointestinal endoscopy performed for a duodenal ulcer, in the second case for first-degree familiarity with a celiac patient, and in the third case because of the presence of malabsorption symptoms. In all three cases, intraepithelial lymphocytes were within the normal range in the first biopsy and cannot, therefore, be considered as a marker of latent celiac disease. In only two of the three patients was it possible to carry out the search for the serum antibodies connected with celiac disease at the time of the first biopsy. In both these cases, the antijejunal antibodies were present before the development of the intestinal lesions.
Adult↗
Bone mass and metabolism in patients with celiac disease.
BACKGROUND & AIMS: Several aspects of the pathogenesis of osteopenia in celiac disease are still unclear. Therefore, bone mass and metabolism were evaluated in adults with celiac disease in a cross-sectional study. METHODS: Bone mineral density (BMD), assessed by total body dual-photon absorptiometry, and serum indices of bone metabolism and remodeling were evaluated in 17 patients with untreated celiac disease, 14 with celiac disease on a gluten-free diet, and 24 healthy volunteers. RESULTS: BMD, expressed as a z score, was significantly lower in patients with untreated celiac disease than in patients with treated celiac disease and volunteers and lower in patients with treated celiac disease than in volunteers. Similar changes were observed in serum calcium level, whereas intact parathyroid hormone level was significantly higher in untreated than in treated patients with celiac disease and volunteers, and no difference was found between the latter two groups. 25-Vitamin D level was significantly lower and 1,25-vitamin D level significantly higher in untreated celiac disease than in treated celiac disease and volunteers. Indices of bone remodeling were significantly higher in untreated than in treated patients and volunteers and significantly and positively correlated with iPTH in untreated patients with celiac disease. CONCLUSIONS: BMD is almost invariably low in patients with untreated celiac disease. Results in treated patients suggest that gluten-free diet improves but does not normalize BMD. Untreated celiac disease is characterized by high levels of 1,25-vitamin D and by increased bone turnover, caused by the increase in intact parathyroid hormone level.
Absorptiometry, Photon↗
Celiac disease and alopecia areata: report of a new association.
Celiac disease is frequently associated with other autoimmune disorders but has never been reported in association with alopecia areata. In a routine clinical practice, 3 patients with such an association were observed. In one of the patients, celiac disease was diagnosed after the occurrence of malabsorption symptoms. In the youngest patient, a 14-year-old boy, gluten-free diet resulted in complete regrowth of scalp and body hair. A prospective screening program for celiac disease using antigliadin and antiendomysial antibodies was therefore set up in 256 consecutive outpatients with alopecia areata. Three patients, all completely asymptomatic for intestinal diseases, were found to be positive and underwent biopsy. Histological analysis showed a flat intestinal mucosa consistent with the diagnosis of celiac disease. The results show that alopecia areata may constitute the only clinical manifestation of celiac disease and that the association between these two conditions is a real one because the observed frequency of association is much greater than can be expected by chance. It is suggested that antigliadin and antiendomysial antibodies should be included in the work-up of patients with alopecia areata.
Adolescent↗
Coeliac disease in adults.
Coeliac disease is a chronic disease characterized by small bowel villous atrophy which impairs nutrient absorption and improves on withdrawal of wheat gliadins and barley, rye and oat prolamins from the diet. Knowledge of the adult form of coeliac disease has greatly improved in recent years. Although this knowledge is not yet sufficiently widespread among referring clinicians, it has, over the past few years, allowed an increasing number of patients to be diagnosed with subclinical forms characterized by minor, transient or apparently unrelated symptoms. As a consequence, our views on the clinical and epidemiological aspects of this condition, the prevalence of which in the general population is believed to be close to 1 in 300, have changed and are still changing. Since it has been demonstrated that a strict gluten-free diet is protective against the complications of adult coeliac disease, it is important that even subclinical and silent forms are diagnosed and treated as early as possible. Non-invasive screening tests, such as anti-gliadin and anti-endomysium antibody estimation, should therefore be used systematically in groups considered to be at risk of coeliac disease. These include first-degree relatives of coeliac patients and patients with insulin-dependent diabetes mellitus, iron-deficiency anaemia, epilepsy with cerebral calcification, recurrent aphthous stomatitis and dental enamel hypoplasia. Other conditions will probably be identified in the near future.
Adult↗
Lactose intolerance and bone mass in postmenopausal Italian women.
Previous studies on the role of lactose malabsorption in the pathogenesis of postmenopausal osteoporosis have yielded conflicting results and further information is needed. To date, all studies have been carried out on populations with a low prevalence of lactose malabsorption and the lactose intestinal absorptive capacity was tested using a non-physiological dose of lactose. In fifty-eight Italian postmenopausal women (mean age 57 (SD 7) years), bone mineral density (BMD) at lumbar spine, H2 breath response after ingestion of 20 g lactose, intensity of symptoms of intolerance after a lactose load and daily Ca intake were evaluated. No differences were found between women with or without a positive H2 breath test with regard to BMD (-1.2 (SD 0.9) v. -0.9 (SD 0.8)) and Ca intake (509 (SD 266) v. 511 (SD 313) mg/d). On the contrary, both BMD and Ca intake were significantly lower in women with lactose malabsorption and symptoms of intolerance (-1.5 (SD 0.7) and 378 (SD 220) mg/d) than in those with malabsorption without symptoms (-0.9 (SD 0.9) and 624 (SD 254) mg/d). Moreover, in lactose malabsorbers Ca intake was correlated inversely with symptom score (rs -0.31, P < 0.05) and positively with BMD (rs 0.42, P < 0.005). Our results show that in Italian postmenopausal women Ca intake and BMD are not influenced directly by lactose malabsorption; the appearance of symptoms of intolerance seems to influence BMD unfavourably through a reduced Ca intake.
Bone Density↗
Wheat deficient in gliadins: promising tool for treatment of coeliac disease.
The toxicity of two varieties of bread wheat, one poor in alpha and beta gliadins and the other poor in alpha, beta, gamma, and omega gliadins, has been tested. The peptic-tryptic digest of these wheats was assessed using coeliac mucosa in an in vitro organ culture system. A significantly lower toxicity was found in respect of bread wheat containing all gliadin fractions. These results suggest new opportunities for the treatment of coeliac disease.
Adult↗
Subclinical coeliac disease is a frequent cause of iron-deficiency anaemia.
BACKGROUND: Although it is known that anaemia may be the only presenting symptom in coeliac disease, prevalence figures of unsuspected coeliac disease in anaemic patients are not available. The aim of this study was to assess the clinical usefulness of antigliadin and antiendomysial antibody tests in the diagnostic algorithm of anaemic patients. METHODS: Two hundred consecutive anaemic patients were tested for antigliadin antibodies, and those positive were also tested for antiendomysial antibodies. All patients positive for antigliadin and antiendomysial antibodies underwent intestinal biopsy. RESULTS: Sixteen patients were antigliadin antibody-positive, and 10 were also antiendomysial antibody-positive. In all 10 a jejunal biopsy was consistent with coeliac disease (prevalence, 5%). This prevalence rose to 8.5% when patients with macrocytic anaemia or with microcytic anaemia due to previous bleeding or responsive to oral iron therapy were excluded from the calculation. CONCLUSIONS: Coeliac disease is a frequent cause of iron-deficiency anaemia, and antigliadin and antiendomysial antibody tests should be always performed in the diagnostic algorithm of anaemic patients.
Adult↗
Splenic autotransplantation after splenectomy: tuftsin activity correlates with residual splenic function.
This study set out to determine the relationship between splenic function (as assessed by the percentage of pitted red cells) and tuftsin activity, and to confirm the return of effective splenic function after splenectomy for trauma. Twenty-three patients (13 men) took part. Ten of mean age 48.5 (range 30-74) years had had the spleen removed for traumatic rupture and 13 of mean age 49.7 (range 23-66) years had undergone elective splenectomy. At the time of the study all patients had had the spleen removed a minimum of 1 year previously (mean 6.1 (range 1-15) years). Fifty healthy volunteers matched for sex and age were also studied. In each subject, residual splenic function was evaluated by counting the percentage of pitted red cells. Tuftsin activity was also determined. A highly significant negative correlation was found between pitted red cell percentage and tuftsin activity (rs = -0.80, P < 0.001). Compared with healthy controls (mean 21.6 (range 13-37) per cent), tuftsin activity was significantly reduced both in patients who had undergone splenectomy for trauma (mean 4.4 (range 0-9) per cent; P < 0.0001) and in those who had had elective splenectomy (mean 0; P < 0.0001). Tuftsin activity was significantly (P < 0.001) more depressed after elective than traumatic splenectomy. These data confirm a decrease in tuftsin activity following splenectomy and show that this deficit is significantly greater after elective than emergency removal. These observations confirm that residual splenic function is often present after traumatic splenectomy.
Adult↗
The effects of levosulpiride on gastric and gall-bladder emptying in functional dyspepsia.
BACKGROUND: 50% of patients with functional dyspepsia have delayed gastric emptying. Levosulpiride is an orthopramide drug that stimulates gastrointestinal motility. Aim of our study was to evaluate the effect of levosulpiride on symptoms and gastric and gall-bladder emptying, in dyspeptic patients. METHODS: Thirty adult patients, treated for 20 days with levosulpiride (75 mg/day) or placebo, were evaluated in a randomized double-blind study. Symptoms were assessed by a cumulative index and overall intensity (visual analogue line). Gastric and gall-bladder emptying were evaluated by epigastric impedance (liquid meal) and real-time ultrasonography (mixed meal). RESULTS: Levosulpiride, with respect to placebo, accelerated the mean gastric half-emptying time of liquids (P < 0.05), gastric emptying (P < 0.001 at 180 min; P < 0.05 at 240 min), and gall-bladder emptying (P < 0.05 at 60 and 120 min) emptying after a solid-liquid mixed meal. Both the mean cumulative index (P < 0.05) and the overall intensity (P < 0.025) of dyspeptic symptoms were reduced significantly by levosulpiride. CONCLUSIONS: Our results showed that levosulpiride can be usefully employed in patients affected by functional dyspepsia.
Adult↗
Osteonecrosis of the femoral head in refractory coeliac disease.
Osteonecrosis has been described occurring in many clinical conditions that require steroid administration. Mechanisms by which steroids produce osteonecrosis are not well known and the importance of the underlying disease has been recently emphasized. We report on a 48-year-old woman with coeliac disease who developed osteonecrosis of the femoral head after being treated with steroids for non-response to gluten withdrawal. We stress the possible role of osteoporosis and osteomalacia, frequently found in patients with coeliac disease, in the pathogenesis of this complication, and advise using drugs other than steroids in the treatment of refractory coeliac disease.
Celiac Disease↗
Subclinical coeliac disease: an anthropometric assessment.
OBJECTIVES: To evaluate the prevalence of malnutrition in patients with untreated coeliac disease (CD) according to their pattern of presentation, and the effect of gluten-free diet (GFD) upon nutritional status. DESIGN: Cohort prospective study. SETTING: All subjects were seen at the outpatient 'malabsorption' clinic of the Department of Medical Pathology I, University of Bologna (referral centre), Bologna. SUBJECTS: Eighty consecutive patients with CD (48 with classical and 32 with subclinical presentation), 15 patients with dermatitis herpetiformis (DH) and 40 healthy volunteers (members of the hospital staff). MAIN OUTCOME MEASURES: The nutritional status was evaluated by anthropometric measurements (percentage of ideal body weight for height and sex, percentage of standard triceps skinfold thickness and percentage of ideal arm-muscle circumference). RESULTS: The overall prevalence of malnutrition in our series of CD patients was 53%. Prevalence of malnutrition (actual body weight less than 90% of the ideal) was significantly higher in classical coeliacs (67%) than in subclinical ones (31%, P < 0.002), in patients with DH (13%, P < 0.0003) and in healthy volunteers (13%, P < 0.0001). At diagnosis, percentage values of ideal body weight, triceps skinfold thickness and arm-muscle circumference were significantly lower (P < 0.0001, P < 0.0002 and P < 0.0003, respectively) in classical coeliacs (84.5 +/- 10.6, 71.2 +/- 28.1 and 87.1 +/- 10.8, respectively) than in subclinical coeliacs (95.5 +/- 9.1, 105.6 +/- 41.0 and 94.8 +/- 10.6, respectively). After GFD, 33% of classical and only 3% of subclinical coeliacs were still malnourished. CONCLUSIONS: Prevalence of malnutrition in CD is lower than was previously thought. CD patients with classical presentation may require a longer period of GFD to achieve a significant improvement of their nutritional status, with respect to those with subclinical presentation, probably because of a greater extent of intestinal damage. Finally, a careful evaluation of dietary habits is usually sufficient to identify incomplete adherence to GFD as the reason for nonimprovement of the nutritional status in patients with CD.
Adult↗
Serological screening of coeliac disease: choosing the optimal procedure according to various prevalence values.
The aim of this study was to select the best approach for screening coeliac disease patients among populations with different grades of disease prevalence. The diagnostic performance was assessed of class A and G antigliadin antibodies and class A antiendomysium antibodies in 93 consecutive outpatients with suspected malabsorption, 44 of whom (47%) had coeliac disease according to duodenal histological tests. Class G antigliadin antibodies provided the worst diagnostic values, whereas a high diagnostic validity was found for the other two tests. The positive predictive value corrected for the disease prevalence expected in coeliac disease relatives (5%) and the general population (0.2%) fell to 30% and < 2% respectively for class A antigliadin antibodies, whereas it remained 100% for antiendomysium antibodies in both situations, providing an optimal value for their use as a screening test and as a valid alternative to duodenal biopsy when this is not feasible. The high cost of anti-endomysium antibodies and the invasive nature of duodenal biopsy prevent them being used widely as screening procedures. A cost effective two step approach was simulated measuring class A antigliadin antibodies in all subjects of the target population (first step), and performing a confirmation test (antiendomysium antibodies or duodenal biopsy) only in subjects positive for antigliadin antibodies. The results show that such a procedure should be recommended only for subjects with an expected low disease prevalence--that is, 5% for coeliac disease relatives and 0.2% for the general population--as the positive predictive value was always 100% with an acceptable false negative rate (6% and 11% respectively), irrespective of which of the two confirmation tests was used. This approach avoids the use of the confirmation test in 63% and 89% of subjects respectively for the two levels of prevalence, resulting in a considerable reduction of the cost. Patients seen for suspected malabsorption with an expected high prevalence of coeliac disease should not have such a serological screening procedure. In conclusion, antigliadin antibodies are useful to screen for asymptomatic coeliac disease in non-hospital communities if antiendomysium anti-bodies are used as a confirmation test: the latter is reasonable valid alternative to duodenal biopsy.
Adolescent↗
The possible role of breath methane measurement in detecting carbohydrate malabsorption.
To evaluate the possibility that measurement of breath methane (CH4) enhances the accuracy of breath hydrogen (H2) testing to diagnose carbohydrate malabsorption, breath CH4 concentration of healthy subjects was studied. Fasting breath CH4 concentration measured three times over a 30-minute period in 44 CH4-producing volunteers ranged from 5 to 120 ppm. Fluctuation of breath CH4 excretion exceeded 100% increase over fasting in 1 of 9 subjects who ingested a nonabsorbable, carbohydrate-free solution. Out of 13 subjects who had a false negative breath H2 response to lactulose, 11 had a CH4 percentage increase greater than 100%. In 11 of 32 lactose-intolerant patients with a negative breath H2 test, CH4 percentage increase after lactose challenge was greater than 100%. These data suggested that in methanogenic individuals, breath CH4 measurement might enhance the accuracy of H2 breath testing in detecting carbohydrate malabsorption.
Adult↗
Asp57-negative HLA DQ beta chain and DQA1*0501 allele are essential for the onset of DQw2-positive and DQw2-negative coeliac disease.
The genetic predisposition to coeliac disease is associated with the HLA DQw2 allele. Coeliac patients lacking the DQw2 allele are very rare and always exhibit the DR4-DQw3 haplotype. We performed oligotyping of polymerase chain reaction (PCR)-amplified DQA1 and DQB1 genes in six DQw2-negative and 30 DQw2-positive coeliac patients. The DQB analysis showed that all six DQw2-negative patients possessed the DQB1*0302 allele. The other DQB alleles found in five of these patients were DQB1*0501, DQB1*0604 and DQB1*0302. The DQ beta chains encoded from all these alleles have the replacement of aspartic acid residue at position 57 (Asp57), as well as the DQB1*0201 allele which was found in all 30 DQw2-positive coeliac patients. The DQw2-negative proband who lacked the homozygous Asp57 replacement exhibited the DQA1*0501 allele in the DQA1 gene. The DQA1*0501 allele was also found in 27 of the 30 DQw2-positive coeliac patients. Among this group of coeliacs, the four cases lacking the DQA1*0501 allele exhibited the homozygous Asp57 replacement in the DQ beta chain. Our results indicate that Asp57-negative DQ beta alleles are involved in both DQw2-positive and -negative coeliac patients. Moreover, when the Asp57-negative DQ beta chain is encoded from only one of the two DQB1 genes the DQA1*0501 allele is always present.
Alleles↗