Notes

Outline

History of the Disease

Aretaeus the Cappadocian  “On the Coeliac Affection”100 AD Symptoms/Signs “Patients have eructations, flatulence and heavy pains of the stomach” “They are emaciated and atrophied, pale, feeble, incapable of performing any of their accustomed work” “The stomach labors in digestion when diarrhea, consisting of undigested food in a fluid state, seizes the patient”

Aretaeus the Cappadocian  “On the Coeliac Affection”100 AD Pathogenesis “Coeliac disease of a chronic nature is formed when the food is dissolved in the heat but the heat does not digest it nor convert it into its proper chyme” “The food being deprived of this operation is changed to a state which is bad in color (white), smell (offensive) and consistence (liquid)”

Aretaeus the Cappadocian  “On the Coeliac Affection”100 AD Epidemiology  “The illness is protracted; intractable and                                                                                                                                                                                                                     relapsing”  “It is familiar to old persons and children;       women more than men” Treatment  “Bread is very little conducive to trim vigor”

Dr. Samuel Gee  1888    “On the Coeliac Affection” “There is a kind of chronic indigestion which is                                                                                                                                                                                                                met  within persons of all ages” “The onset is usually gradual...sometimes the      complaint sets in suddenly” “The patient wastes more in the limbs than in                                                                                                                                                                                                                    the face; the belly is distended” “At times the bowel complaint is overlooked;      wasting, weakness, paleness are noticed”

Dr. Samuel Gee  1888    “On the Coeliac Affection” “Errors in diet may perhaps be a cause.....      to regulate the food is the main part of                                                                                                                                                                                                                    treatment” “The allowance of farinaceous food must be                                                                                                                                                                                                                       small; highly starchy food, rice, sago, corn-                                                                                                                                                                                                                  flour are unfit” “Malted food is better, also rusks or bread cut                                                                                                                                                                                                                  thin and well toasted on both sides”

Historic Hallmarks in the 20th Century 1914  Poynton Bread and butter exacerbated the symptoms in one reported case Constipation rather than diarrhea may      be troublesome Natural tendency to remit in adolescence

Historic Hallmarks in the 20th Century 1918 Still “One form of starch which seems particularly   liable to aggravate the symptoms is bread” 1923 Miller  Fat absorption could be abnormal in the                                                                                                                                                                                                                        absence of symptoms  Adults could remain well on a normal diet

Historic Hallmarks in the 20th Century 1924   Haas Successfully treated 8 patients with bananas, castor oil, and colonic irrigation 1929   Holmes & Starr Coined the term "Non-Tropical Sprue" 1929   Thaysen Coined the term "Idiopathic Steatorrhea" to unify childhood and adult disease

Historic Hallmarks in the 20th Century 1932 Dusseldorp & Stheeman Relapses of diarrhea preceded by consumption of bread and rusks 1936  Dicke Told by a young mother that her child’s rash improved if she removed bread from the diet 1941  Dicke Recommendations for wheat-free diet

Conclusions of Dicke’s Doctoral Thesis Celiac disease is caused by the harmful effects of wheat, barley, rye, and oat flour It is gliadin, an alcohol soluble subfraction of gluten, that is the deleterious factor (not starch) Following removal of gluten from the diet, there is a time lag before symptoms disappear, or reappear with its re-introduction

Classical Presentation and Traditional Approach to Celiac Sprue

Common Misconceptions About Gluten Sensitivity/Celiac Sprue Patients cannot have gluten sensitivity/celiac sprue: If they have not lost weight If they are obese If they have no intestinal symptoms If they are elderly If they have negative screening blood tests If they have no steatorrhea If they have a normal small bowel biopsy

Celiac Sprue Traditional Definition Symptoms or signs due to malabsorption of fluid, electrolytes, and/or nutrients Small intestinal histopathology Inflammation of lamina propria Intraepithelial lymphocytosis Villous atrophy Crypt hyperplasia Clinical improvement with gluten-free diet

Celiac Sprue  Populations at Risk Mainly in Northwestern and Southern Europeans More frequent in women Also in Near-East, Middle-East, Latin America Rare or nonexistent in Africa, Far-East

Theoretical Explanation for High Prevalence of Celiac Sprue in Descendants of Northwest Europe Evolutionary selection of disease-associated genotype (HLA +/- others) Enhanced immunity to infections Physiologic ability to digest lactose after weaning Exposure to unique endemic triggering factors or lack of exposure to protective ones Greater use and development of wheat as a food source in the same geographic region

Celiac Sprue - Etiology Consumption of gluten contained in:       Wheat, Barley,Rye, Oats Toxic alcohol soluble subfraction of wheat gluten is gliadin

Celiac Sprue  Immune Pathogenesis Evidence of an immunologic reaction: Increased Ab-producing immunocytes in lamina propria Anti-gliadin Ab in intestine and serum Increased intraepithelial  T-lymphocytes Increased cytokine production in mucosa

Celiac Sprue - Pathogenesis Genetic predisposition 70% concordance in identical twins Increased prevalence in 1o relatives Disease associated with HLA haplotypes Environmental factors Infection with type 12 adenovirus (?) Other unknown factors

Pathogenesis of Celiac Sprue Immunological events triggered by alcohol soluble storage proteins of certain grains    Wheat - gliadins       Rye - secalins                       Barley - hordeins      Oats - avenins Prolamin-derived peptides processed and presented to T cells by HLA class II molecules Damage thought to be mediated by activated HLA-DQ restricted T cells

Immune Events Following Exposure of SB Biopsies to Gliadin in vitro Earliest (direct) events (1-2 hours) Upregulation of HLA-DR expression on villous enterocytes and macrophages  ICAM-1 expression by LP mononuclear cells Intermediate events (4-12 hours) Upregulation of HLA-DQ expression on lamina propria mononuclear cells Migration of activated CD4+ T cells and macrophages to subepithelial compartment

Immune Events Following Exposure of SB Biopsies to Gliadin in vitro Late events (>24 hours) Expression of IL-2 receptor (CD25) by lamina propria T cells and macrophages Invasion of epithelium by CD8+ T cells (IEL) Production of antiendomysial Ab Maiuri et al Gastroenterology 1996

Mechanism of Gliadin-Induced Small Intestinal Damage Gliadin/peptides derived from its digestion induce intestinal damage in genetically pre-disposed individuals (HLA-DQ2 or -DQ8) by direct toxic and immune-mediated mechanisms Triggering events and whether antibodies to “endomysium” (tissue transglutaminase) are pathogenetic remain to be identified

Theoretical Immune System Triggers for Celiac Sprue Loss of oral tolerance to gluten Intestinal infections or SB bacterial overgrowth Other infections or states inducing autoimmunity Similar immune reactions elsewhere in the body Increased intestinal permeability to antigens Loss of inhibition or promotion of gene activity Altered or impaired gluten digestion Increased dietary gluten intake

Theoretical Immunological Changes Induced by Trigger Enhanced antigen presentation Recruitment of specific T cells to the SI mucosa Upregulation of HLA class II antigen expression Failure of local immunosuppressive mechanisms Enhanced humoral activity toward foreign agents and/or self

Celiac Sprue -  Symptoms of Classical Form      GI                           Non-GI Weight loss       Weakness Flatulence       Paresthesias Diarrhea               Muscle spasms Distention               Bone pain Bloating               Night blindness Vomiting               Amenorrhea

GI Symptoms in  78 Celiacs Before and After GFD                             Before GFD      After GFD                                 n       (%)          n      (%) Weight loss           64 (82)         0       (0) Chronic diarrhea           62 (79)       13      (17) Excessive flatulence      58 (74)         0       (0) Bloating/distention         53 (68)         0       (0) Nausea           28 (36)         0       (0) Vomiting           15 (19)         0       (0) Constipation             5 (6)         1       (1) No symptoms             4 (5)         0       (0) (iron deficiency anemia)                                                                                                                Data from Fine et al Gastroenterology 1997;112:1830

Celiac Sprue - Signs of Classical Form Steatorrhea Anemia  (iron, folate, vitamin B12 def) Osteopenia Peripheral neuropathy Hyposlenism Decreased serum Ca, Mg, Zn, PO4, albumin, cholesterol, carotene Increased alk phos, PT, platelets

Celiac Sprue - Pathology Total villous atrophy Elongated, hyperplastic crypts Cuboidal epithelium (rather than columnar) Proliferation of plasma cells and lymphocytes in lamina propria Intraepithelial lymphocytosis

Differential Diagnosis of Pathologic Lesion Tropical sprue Primary small intestinal lymphoma Intestinal stasis with bacterial overgrowth Infectious gastroenteritis Eosinophilic gastroenteritis Zollinger-Ellison syndrome Crohn’s disease Hypogammaglobulinemia (CVID)

Newer Understanding of the Spectrum of Gluten Sensitivity

Celiac Sprue Clinicopathologic Spectrum Clinical presentation Asymptomatic (with or without iron deficiency) Abdominal bloating, nausea, G-E reflux Diarrhea, weight loss, symptoms of fat malabsorption Histopathology Mild intraepithelial lymphocytosis or plasmacytosis of LP, normal villi and crypts Partial or subtotal villous atrophy and inflammation Total villous atrophy, inflammation, crypt hyperplasia

“Gluten-Sensitive Diarrhea without Evidence of Celiac Disease” 8 female patients with chronic diarrhea (0.6-20 yrs) Explosive, watery, nocturnal Malaise, anorexia, weight loss, abdominal pain Normal labs (   serum folate in three); no steatorrhea Small intestinal histology Villi normal; increased #’s plasma cells and IEL’s Resolution of diarrhea and SB inflammation on GFD; recurrence with gluten challenge                                  Cooper et al  Gastroenterology  1980;79:801

“Gluten-Sensitive Disease with Mild Enteropathy” 10 pts. with chronic  diarrhea/steatorrhea, iron def. anemia, osteoporosis, aphthae,   Ca, or   LFT’s All had AEA; mildly   AGA in 4;    xylose in 6 of 8 SB histology: villi normal;    IEL’s in 4; all had immunohistochemical markers of immune activation    ICAM-1, CD25, CD80 in MNC’s;    HLA-DR in crypts Positive in vitro challenge of biopsies with gliadin All symptoms and histopathology resolved on GFD                                    Picarelli et al  Gastroenterology  1996;111:608

Evolving Spectrum of Mild Disease Increased awareness of disease Identification of familial tendency Indentification of epidemiologically associated diseases Development and implementation of screening methods

Diagnostic Accuracy of Serum Antigliadin and Antiendomysial Ab*               Sensitivity    Specificity Anti-gliadin IgG         95%                    65% Anti-gliadin IgA         80%                    85% Anti-endomysial          90%                   100%

Prevalence of Celiac Serologic Test Positivity in 227 Normal Volunteers

Tests of Abnormal SB Function in AGA-positive Volunteers

Example of Mild Intestinal Inflammation without Villous Atrophy

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New Screening Protocol for Gluten Sensitivity Featuring Our New Stool Fecal Tests

Screening Protocol for Clinically Important Gluten Sensitivity Stool Quantitative sudan stain for steatorrhea Fecal antigliadin and antitissue transglutaminase IgA Hemoccult Lactoferrin  (if stool soft or liquid) Buccal smear HLA - DQ typing by molecular methodology Blood (if easily attainable) Antigliadin IgG / IgA; antitissue transglutaminase IgA

Fecal Antigliadin Antibody Testing              Group                        Positivty rate Untreated celiac sprue (n=20)   100% Microscopic colitis (n=63)      75% Chronic diarrhea (n=182)     49% Normals (n=37)     32% Symptomatic (n=14)     57% Treated celiacs (n=11)       9%

Comparison of Serum and Fecal Antigliadin Ab Positivity

Inaccuracy of Quantitative Stool Collection for Diarrhea 30% of patients do not collect all stools No difference between:  24, 48, or 72 hr collection periods Inpatients and outpatients Worse as frequency of BM increases

Relation of BM Frequency and Stool Collection Inaccuracy

Quantitative Sudan Fat Stain New method of Sudan fecal fat microscopy   (Fine, Ogunji  In press Am J Clin Path  April 2000) Allows quantitation of fecal fat output from a single spot stool specimen Easily establishes a numeric pretreatment baseline for intestinal nutrient malabsorption  More sensitive than old qualitative method

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Diagnostic Accuracy of Quantitative Sudan Stain Sensitivity 97% Positive predictive value 100% Specificity 100% Negative predictive value   95%

Autoimmune and Other Diseases Associated with Gluten Sensitivity

Antigen Substrate for Antiendomysial Antibodies Tissue transglutaminase (Dieterich et al Nature Med 1996) 85 kd enzyme responsible for protein crosslinking Secreted extracellularly in response to tissue injury Activates transforming growth factor $ for collagen synthesis and epithelial cell differentiation Can bind gliadin as a substrate Serum ELISA test for this enzyme highly sensitive and specific for celiac disease (similar to AEA) Celiac sprue therefore is an autoimmune disorder

Main Autoimmune Diseases Associated with Celiac Sprue Diabetes mellitus, type 1 Microscopic colitis Dermatitis herpetiformis Asthma Sjogren’s syndrome, rheumatoid arthritis, others Thyroiditis Autoimmune hepatitis, PBC, Hepatitis C Psoriasis

Duration of Gluten Consumption and Risk of Autoimmune Disease

Other Syndromes Associated with Gluten Sensitivity Chronic liver disease Chronic diarrhea of unknown origin Osteoporosis Iron deficiency Short stature in children Down’s syndrome Female infertility Mother’s of children with neural tube defects

Syndromes Possibly Associated with Gluten Sensitivity Irritable bowel syndrome Inflammatory bowel disease Gastroesophageal reflux disease Autism

Causes of Chronic Diarrhea Identifiable causes 30% Microscopic colitis 10% Osmotic diarrhea   9% IBD   4% Scattered other diagnoses   7% Unidentifiable causes 70%

Fecal Antigliadin Antibody Testing              Group                        Positivty rate Untreated celiac sprue (n=20)   100% Microscopic colitis (n=63)      75% Chronic diarrhea (n=182)     49% Normals (n=37)     32% Symptomatic (n=14)     57% Treated celiacs (n=11)       9%

Prevalence of Celiac Serologic Test Positivity in Liver or GI Patients

Five Liver Patients Found to Have Antiendomysial Antibody

Immensity of Gluten Sensitivity as a Public Health Problem

Normal Prevalence of Potentially Gluten Sensitive HLA Genes HLA - DQ2    31% HLA - DQ8    12% HLA - DQ1,7    18% HLA - DQ1,9        1% Other HLA and non-HLA genes   ? Total     62% +

Clinical Spectrum of Immunologic Gluten Sensitivity

Old and New Estimates of Prevalence of Celiac Sprue and  Gluten Sensitivity, Respectively Old - Celiac sprue Clinical presentation    1 in 2000-5000 Serologic screening     1 in 250 New - Gluten sensitivity Serum antigliadin Ab    1 in 8 Fecal screening 1 in 3

Who should be screened for gluten sensitivity? Chronic diarrhea of unknown origin Microscopic colitis Dermatitis herpetiformis Diabetes mellitus, type 1 Any autoimmune syndrome Hepatitis C Asthma

Who should be screened for gluten sensitivity? (cont.) Chronic liver disease Osteoporosis Iron deficiency Short stature in children Down’s syndrome Female infertility Mother’s of children with neural tube defects

Who should be screened for gluten sensitivity? (cont.) Irritable bowel syndrome Inflammatory bowel disease Gastroesophageal reflux disease Autism Everyone

Treatment and Follow -Up If Found to Be Gluten Sensitive (especially with enteropathy)

Celiac Sprue - Treatment Gluten-free diet - strict, indefinite   Necessary degree of gluten restriction for                                                                                                                                                                                                                        patients to remain asymptomatic varies Avoid lactose initially Folate Sometimes Fe, Ca, Mg

Celiac sprue/Gluten Sensitivity  Follow-Up Immediately Consult with an expert dietitian Attend a celiac sprue support group Establish baseline fecal and/or serum antigliadin Ab titer, and quantitative fat microscopy

Celiac sprue/Gluten Sensitivity  Follow-Up 1 and 6 Months Assess symptoms Measure body weight Blood count (if very anemic pre-treatment) Antigliadin Ab and fecal fat microscopy, HLA-gene testing (if not doing well)

Celiac sprue/Gluten Sensitivity  Follow-Up 12 - 24 Months and Subsequently Assess symptoms and body weight Fecal Antigliadin IgA antibody Quantitative fat microscopy Consider bone densitometry Watch for weight gain Maintain healthy diet and lifestyle

Diets With or Without Oats in Adults With Celiac Disease 52 patients with celiac disease in remission 40 patients newly diagnosed ½ of each group given oats for 6-12 mos Compared symptoms and biopsies before and after Found no “significant” differences in outcome      NEJM 1995;333:1033

Diets With or Without Oats in Adults With Celiac Disease My observations and cautions: 50% of previously diagnosed, 20% of newly diagnosed patients were excluded 13% of patients getting oats withdrew from the study  (no reasons given) Because oats are the least toxic grain, damage may take longer than 6-12 mos No physiologic or immunologic testing

Results from Some of Dr. Fine’s Research Studies

Occult GI Bleeding in  Celiac Sprue Background: Iron deficiency is common in celiac sprue, traditionally thought to be caused by:   Malabsorption of dietary iron       Sloughing of intestinal cells Purpose of Study: To determine the prevalence of GI blood loss in patients with celiac sprue            NEJM 1995;334:1163

Results of Fecal Hemoccult Testing in Celiac Sprue                        (n)       % positive Controls                178             6 Untreated Sprue Patients Partial villous atrophy    8         25 Total villous atrophy        28            54 Treated Sprue Patients    7           0

Prevalence and Causes of Chronic Diarrhea in Treated Celiac Sprue The majority of sprue patients have diarrhea before diagnosis;the frequency and causes of diarrhea following Rx has not been studied. Surveyed 78 patients with treated celiac sprue about their bowel habits. Those passing loose stools more frequently than 3 times per week for 6 months were investigated. Gastroenterology 1997;112:1830

Frequency of Loose Stools in Celiacs After Rx With GFD                                                                                        n Daily 3 Frequently (on 3 or more days/week) 10 Sometimes (once every 1-2 weeks)     13 Rarely (1-2 times per month) 15 Almost Never (0-2 times per six months) 37

Causes of Chronic Diarrhea in 12 Patients With Treated Celiac Sprue      Diagnoses                               n    Microscopic colitis                           4 Carbohydrate malabsorption          2          (lactose, fructose)    Irritable bowel syndrome                2    Pancreatic insufficiency                  2    Fecal incontinence   2

Celiac Sprue and the Colon Endoscopically normal Histologically normal in the majority Morphometrically, increased numbers of lymphocytes in epithelium and LP Over time, 3-5% develop microscopic colitis, even those on a gluten-free diet No increase in polyp or cancer incidence

“Secondary” Gluten-Sensitivity in Microscopic Colitis Antigliadin Ab: less prevalent and lower titers than celiac sprue;usually IgG or IgA, not both Antiendomysial Ab: less prevalent than CS Enteropathy usually mild L.P. inflammation +/-  pva or sva Minimal or no steatorrhea May respond to treatment of the colitis with bismuth subsalicylate

Speculations on the Pathogenesis of Microscopic Colitis HLA-directed T-cell reaction to an antigenic stimulus in the colonic lumen Not gluten or other dietary derivative Related to bacteria or another microorganism Potentiated by NSAID’s and possibly estrogen supplements Antibiotics or other factors related to alteration of colonic flora

Refractory Sprue Clinicopathologically identical to celiac sprue but no response to gluten-free diet or relapse following initial response Causes Inadvertent or deliberate ingestion of gluten Immune sensitivity to other dietary antigens Coexistent intestinal lymphoma Another diagnosis

Refractory Sprue Rx-steroids; other immunosuppressives Prognosis is variable but generally poor Frequent presence of microscopic colitis    Surface epithelial damage       mononuclear cells in lamina propria        Intraepithelial lymphocytosis

Colonic Histology at Diagnosis and Response to a GFD     Colonic                 Response          No Response    Histology             to GFD                 to GFD Normal (n=12)                11                                   1 Inflamed (n=6)                            0                        6 (microscopic colitis)