IgA endomysium antibodies--an early predictor for celiac disease in children without villous atrophy.

AIM: To evaluate possible differences between children with anti-endomysium antibodies (EMA) positivity and normal small bowel mucosa and children with positive EMA and an enteropathy diagnosed as celiac disease (CD). METHODS: Children with suspected CD and positive EMA (>or=1/10) undergoing small bowel biopsy during 1996 to 2002, were investigated (n=133). Data registered were: year and month of birth, timing of the first biopsy, sex, heredity for CD, dermatitis herpetiformis and diabetes mellitus and outcome of the anti-gliadin antibody test (AGA). The case group, with EMA positivity and normal histology (n=39; 59% female, mean age at the first biopsy 7.3 years, range 1.4-16), was compared with the disease control group, with positive EMA and a biopsy suggestive and further on diagnosed as CD (n=94; 56% female; mean age 7.6 years at the first biopsy, range 0.70-17). RESULTS: AGA positivity and heredity for CD were found to predict the outcome of a pathological jejunal mucosa. Nineteen of the 39 children in the case group were rebiopsied of whom 11 had developed an enteropathy during a follow-up period of 2-7 years (median 4.5 years). CONCLUSIONS: EMA positivity in the absence of small bowel enteropathy could be a very early predictor for later overt CD, and necessitates further follow-up, especially if the child is AGA positive and there is a family history of CD.

Gut microflora associated characteristics in children with celiac disease.

OBJECTIVES: The aim of the study was to investigate the metabolic function of intestinal microflora in children with celiac disease (CD) in order to find out if there is a deviant gut flora in CD patients compared to healthy controls. METHODS: The study group comprised children with CD, consecutively diagnosed according to current criteria given by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition. Thirty-six children were studied at presentation, i.e., on a normal gluten-containing diet, with clinical symptoms and signs indicative of CD, positive celiac serology markers, and a small bowel biopsy showing severe enteropathy. Forty-seven patients were studied when they had been on a gluten-free diet (GFD) for at least 3 months. For comparison, a group of 42 healthy controls (HC) were studied. The functional status of the intestinal microflora was evaluated by gas-liquid chromatography of short chain fatty acids (SCFAs) in fecal samples. RESULTS: There was a significant difference between untreated CD children and HC as well as between treated CD children and HC regarding acetic, i-butyric, i-valeric acid, and total SCFAs. The propionic and n-valeric acids differed significantly between CD children on GFD and HC. Moreover, there was a strong correlation between i-butyric and i-valeric acids in all study groups. CONCLUSIONS: This is the first study of the SCFA pattern in fecal samples from children with CD. The results indicate that there is a difference in the metabolic activity of intestinal microbial flora in children with CD compared to that in HC. The finding of a different pattern of some SCFAs in celiacs both at presentation and during treatment with GFD indicates that it is a genuine phenomenon of CD not affected by either the diet, the inflammation, or the autoimmune status of the patient.

Increasing prevalence of coeliac disease in Swedish children: influence of feeding recommendations, serological screening and small intestinal biopsy activity.

BACKGROUND: The prevalence of coeliac disease (CD) in Swedish children has attracted considerable interest over the past few decades, and especially the influence of feeding habits on the increased incidence. A national study has reported a trend towards a decrease in incidence after a change in infant feeding recommendations was introduced in 1996. The aim of this study was to evaluate, in a geographically defined area, the change in incidence with time and the influence of the introduction of antibody analysis. METHODS: Cases of suspected paediatric CD between 1980 and 2003 were studied for prevalence, biopsy findings and antibody analyses. RESULTS: A total of 2029 children were investigated by small intestinal biopsy, yielding 554 CD cases. The area initially showed the same trend as the national study, but the annual incidence rate is now increasing again. Median age at diagnosis has increased significantly since 1997 from less than 2 years of age to above 5 years. Cumulative incidence at 2 years of age is much higher for the birth cohorts 1983-96 than 1980-82 or 1997-2001. Diagnostic accuracy was significantly higher after the introduction of antigliadin (AGA) analysis, and especially after antiendomysium (EMA) analysis. CONCLUSIONS: The incidence rate of CD in small children in our region has varied widely over the 24-year period observed. Feeding practice and methods of investigation have changed during this period. The annual incidence rate for the total child population in 2003 was almost equal to the peak value observed in 1994. There were no conclusive results on whether antibody analysis had an influence on diagnostic activity, but this seems to have increased diagnostic accuracy.

Elemental versus polymeric enteral nutrition in paediatric Crohn's disease: a multicentre randomized controlled trial.

AIM: To compare the efficacy and safety of an elemental and a polymeric diet as the primary therapy for active Crohn's disease in children. METHODS: In a randomized, non-blind, multicentre, controlled trial in Sweden, 16 children with Crohn's disease received Elemental 028 Extra (E028E) and 17 Nutrison Standard (NuS). Remission rates (Paediatric Crohn's Disease Activity Index (PCDAI) < 10 or a PCDAI decrease of 40% or 15 points of initial level) were compared at 6 wk. RESULTS: There was no significant difference between the two groups in remission rate at 6 wk (intent-to-treat analysis): E028E 11/16 (69%) and NuS 14/17 (82%) (p = 0.438). There was no difference in the decrease in PCDAI and CDAI between patients treated with E028E and those treated with NuS from 0 to 6 wk. Patients treated with NuS gained significantly more weight than patients treated with E028E (+2.5 kg; 95% CI 0.9, 4.1; p = 0.004), this difference remained when adjusting for maximum caloric intake per kilogram bodyweight (+2.9 kg; 95% CI 1.4, 4.5; p = 0.001). Concomitant disease, complications and side effects were seen in 5/33 patients (pyelonephritis, pneumonia, intraabdominal abscess, perianal abscess and borborygmi). CONCLUSION: E028E and NuS did not differ in terms of remission rate. Patients treated with NuS gained more weight than patients with E028E. Polymeric diet may be superior to elemental diet in the treatment of paediatric Crohn's disease where the primary aim is to increase the patient's weight.

Oats to children with newly diagnosed coeliac disease: a randomised double blind study.

BACKGROUND: Treatment of coeliac disease (CD) requires lifelong adherence to a strict gluten free diet (GFD) which hitherto has consisted of a diet free of wheat, rye, barley, and oats. Recent studies, mainly in adults, have shown that oats are non-toxic to CD patients. In children, only open studies comprising a small number of patients have been performed. AIM: To determine if children with CD tolerate oats in their GFD. PATIENTS AND METHODS: In this double blind multicentre study involving eight paediatric clinics, 116 children with newly diagnosed CD were randomised to one of two groups: one group was given a standard GFD (GFD-std) and one group was given a GFD with additional wheat free oat products (GFD-oats). The study period was one year. Small bowel biopsy was performed at the beginning and end of the study. Serum IgA antigliadin, antiendomysium, and antitissue transglutaminase antibodies were monitored at 0, 3, 6, and 12 months. RESULTS: Ninety three patients completed the study. Median (range) daily oat intake in the GFD-oats group (n = 42) was 15 (5-40) g at the six month control and 15 (0-43) g at the end of the study. All patients were in clinical remission after the study period. The GFD-oats and GFD-std groups did not differ significantly at the end of the study regarding coeliac serology markers or small bowel mucosal architecture, including numbers of intraepithelial lymphocytes. Significantly more children in the youngest age group withdrew. CONCLUSIONS: This is the first randomised double blind study showing that the addition of moderate amounts of oats to a GFD does not prevent clinical or small bowel mucosal healing, or humoral immunological downregulation in coeliac children. This is in accordance with the findings of studies in adult coeliacs and indicates that oats, added to the otherwise GFD, can be accepted and tolerated by the majority of children with CD.

Conscious or deep sedation: a questionnaire regarding the experience of parents, children and staff during small bowel biopsy.

AIM: The paediatric clinics of Linköping and Norrköping, Sweden, have different procedures regarding premedication and sedation during small bowel biopsy in children with suspected or diagnosed coeliac disease. In Linköping deep sedation using intravenous propofol is the method of sedation being used and parents are not present during the biopsy procedure. In Norrköping conscious sedation using intravenous midazolam is the routine and parents stay with their child throughout the whole biopsy procedure. The aim of this study was to find out whether the preprocedural and procedural differences between the clinics affected the way in which the parents and children experienced the time before and during the biopsy procedure. METHODS: A questionnaire was used to ask the parents of 102 children who had undergone small bowel capsule biopsy for their opinion regarding the discomfort experienced by their children. The parents' and children's experience was also compared with that of the paediatric nurse caring for the family during the biopsy procedure, and the paediatric gastroenterologist performing the biopsy. RESULTS: The differences regarding premedication and sedation between the two groups did not seem to affect the parents' or the children's total experience of the biopsy procedure, nor did the presence or absence of the parents throughout the biopsy procedure. As regards the sedation given, 95% of the parents did not think that their children suffered any discomfort at all. The total experience of the biopsy procedure on a five-grade scale (5 being very good, 1 being very bad) was 5 for the parents and 4 for the children in both centres. Parents and children in both centres were very satisfied with the way in which they were taken care of during their visit to the hospital. In both units there was an obvious correlation between how the paediatric nurse experienced the biopsy procedure and how the paediatric gastroenterologist did, but only a weak correlation between the experience of the parents and that of the paediatric gastroenterologist and paediatric nurse. The anxiety of the parents was similarly estimated by the paediatric gastroenterologist and the paediatric nurse in both centres. There was no correlation between their assessment and the experience reported by the parents. CONCLUSION: The children undergoing small bowel biopsy and their parents felt well taken care of during their visit to the two hospitals. The differences between the clinics regarding method of sedation and presence or absence of the parents did not seem to affect how the parents and children experienced the biopsy procedure.

Familial prevalence of coeliac disease: a twenty-year follow-up study.

BACKGROUND: The genetic predisposition of coeliac disease (CD) is well known. Previous studies of first-degree relatives of coeliac patients have shown that as many as 10% have the disease. In 1981, we published a study in which all first-degree relatives of 32 index patients with CD were investigated by small-bowel biopsy. We found 2 relatives (2%) with CD. The present study is a re-investigation of all first-degree relatives of the same index patients performed 20-25 years after the first study to reveal any new cases of CD in this high-risk population. METHODS: All 120 first-degree relatives were screened for CD by means of serological markers of CD. The relatives with positive markers were submitted to small-bowel biopsy. RESULTS: Eight new cases of CD were found among the relatives. Two had been investigated by small-bowel biopsy 20 years previously, when they had only minor mucosal changes not classified as CD. The other six new cases of CD were found among offspring of the index patients and were born after completion of the previous study. Thus no new case of CD was found among those relatives who had a completely normal small-bowel biopsy 20-25 years previously. CONCLUSIONS: The high prevalence of CD among first-degree relatives of coeliac patients (8.3% in this study) supports the need to screen for CD in this high-risk population. Even relatives with only mild enteropathy should be followed carefully, since some may subsequently develop CD.

Small bowel biopsy in Swedish paediatric clinics.

AIM: A correct diagnosis of coeliac disease, one of the most common chronic diseases in Swedish children, demands small bowel biopsy, which can be performed endoscopically or by means of a peroral capsule. Recently there was a debate among Swedish paediatric gastroenterologists, with some advocating the cessation of capsule biopsy in favour of endoscopic biopsies. To gain information on which to base a recommendation for which technique to use, the Swedish Working Group for Childhood Coeliac Disease was commissioned to carry out a national questionnaire study on current small bowel biopsy routines in Swedish paediatric clinics. METHODS: A questionnaire concerning biopsy routines in the year 2000 was sent to all paediatric clinics performing biopsies. A reply was obtained from 39 of 40 clinics, covering 98% of the Swedish population. RESULTS: Some 1400 biopsies were performed, 64% of which were capsule biopsies and 36% endoscopic. Three clinics performed all biopsies endoscopically and 11 clinics all via a capsule. At endoscopy all children were under deep sedation or full anaesthesia, while most children undergoing capsule biopsy were under light or deep sedation. The oxygen saturation was monitored during endoscopy but less often or never during routine capsule biopsy. The presence of the parents during biopsy varied according to the degree of sedation: at 97% of the clinics performing capsule biopsy on children under light sedation, the parents were present during the whole procedure, whereas no parents were present at clinics where the biopsy was performed endoscopically under anaesthesia. CONCLUSION: Compared with the results of a similar questionnaire concerning biopsy routines performed in the early 1990s, children are now more effectively sedated. Furthermore, there is an obvious trend from capsule towards endoscopic biopsy. Both the endoscopic and the capsule biopsy techniques are useful and satisfactory for obtaining small bowel mucosal samples providing that the children are effectively sedated. For practical and economic reasons the capsule biopsy technique will probably continue to be used, although to a lesser extent than today.

Variation in the CTLA4/CD28 gene region confers an increased risk of coeliac disease.

Susceptibility to coeliac disease involves HLA and non-HLA-linked genes. The CTLA4/CD28 gene region encodes immune regulatory T-cell surface molecules and is a strong candidate as a susceptibility locus. We evaluated CTLA4/CD28 in coeliac disease by genetic linkage and association and combined our findings with published studies through a meta-analysis. 116 multiplex families were genotyped across CTLA4/CD28 using eight markers. The contribution of CTLA4/CD28 to coeliac disease was assessed by non-parametric linkage and association analyses. Seven studies were identified that had evaluated the relationship between CTLA4/CD28 and coeliac disease and a pooled analysis of data undertaken. In our study there was evidence for a relationship between variation in the CTLA4/CD28 region and coeliac disease by linkage and association analyses. However, the findings did not attain formal statistical significance (p = 0.004 and 0.039, respectively). Pooling findings with published results showed significant evidence for linkage (504 families) and association (940 families): p values, 0.0001 and 0.0014 at D2S2214, respectively, and 0.0008 and 0.0006 at D2S116, respectively. These findings suggest that variation in the CD28/CTLA4 gene region is a determinant of coeliac disease susceptibility. Dissecting the sequence variation underlying this relationship will depend on further analyses utilising denser sets of markers.

Mutational analysis of CD28 in coeliac disease.

BACKGROUND: Coeliac disease shows a strong genetic predisposition involving HLA-DQ2 and non-HLA components. The CD28 cell surface molecule, encoded by CD28, represents a potential candidate coeliac disease susceptibility gene. Furthermore, some studies have demonstrated linkage to the CD28/CTLA4 gene region. To investigate whether germline mutations in CD28 contribute to coeliac disease susceptibility, we have carried out a comprehensive analysis of the gene in Swedish patients with biopsy-proven disease. METHODS: Blood samples were collected from 52 children with biopsy proven coeliac disease attending one Swedish centre. DNA was extracted from lymphocytes and all exons and intron-exon boundaries of CD28 were screened for mutations. Analysis of CD28 was undertaken by a combination of conformation specific gel electrophoresis and direct sequencing. RESULTS: Three sequence variants were identified: a synonymous G-->4A substitution at position 3 of codon 35 encoding alanine, a synonymous G-->A substitution at position 3 of codon 70 encoding glycine, and a T-->C substitution at nucleotide +17 of intron 3. No pathogenic variants were detected. CONCLUSIONS: There is no evidence from this study that mutations in CD28, which lead to an altered protein, contribute to coeliac disease susceptibility.

Analysis of the CTLA4 gene in Swedish coeliac disease patients.

BACKGROUND: A genetic susceptibility to coeliac disease is well established, involving HLA and non-HLA components. CTLA4 is an important regulator of T-cell function and some studies have suggested that sequence variation in the gene might be a determinant of disease susceptibility, although the evidence is conflicting. METHODS: Sixty-two children with biopsy-proven coeliac disease attending a single centre in Sweden were studied. All were genotyped for presence of the HLA-DQA1*0501, B 1*0201 alleles. Those who carried the HLA-DQ heterodimer (58/62) were genotyped for the +49 (A/G) exon I polymorphism. The transmission disequilibrium test (TDT) was used to test for association between coeliac disease and the A allele. The entire CTLA4 gene was screened for other sequence variants using a combination of conformation-sensitive gel electrophoresis and direct sequencing. RESULTS: A significant association between the exon I polymorphism and coeliac disease was observed (P = 0.02). No other sequence variants in CTLA4 were detected. CONCLUSIONS: This study provides further evidence that variation in CTLA4 is a determinant of coeliac disease susceptibility. If not mediated through the +49 (A/G) dimorphism directly, then the effect is likely to be mediated through linkage disequilibrium.

Germline mutations in TGM2 do not contribute to coeliac disease susceptibility in the Swedish population.

OBJECTIVE: Coeliac disease (CD) shows a strong genetic predisposition involving HLA-DQ2 and non-HLA components. Tissue transglutaminase, encoded by TGM2, occupies a central role in the CD pathogenesis, necessary for the deamidation of specific glutamine residues of alpha-gliadin creating a T-cell epitope that binds with increased affinity to DQ2. To investigate whether germline mutations in TGM2 contribute to disease susceptibility we have carried out a comprehensive analysis of the gene in 52 patients with CD. DESIGN: Blood samples were collected from 52 children with biopsy proven CD attending one Swedish centre. DNA was extracted from lymphocytes and all exons and intron-exon boundaries of the TGM2 gene and the alternatively spliced form of the gene were screened for mutations. METHODS: Mutational analysis was undertaken by a combination of conformational specific gel electrophoresis and direct sequencing. RESULTS: Three novel polymorphisms were identified but no pathogenic mutations were detected. CONCLUSIONS: There is no evidence from this study that mutations in TGM2, which lead to an altered protein, contribute to CD susceptibility.

One thousand small-bowel biopsies in children. A single-port versus a double-port capsule.

BACKGROUND: Small-bowel biopsy is a well-established technique in the evaluation of children with intestinal malabsorption, e.g. coeliac disease. The biopsy is performed endoscopically or with a peroral capsule instrument. The aim of the present retrospective study was to compare the single-port Watson capsule with the double-port Storz capsule with regard to procedure and fluoroscopy time, complications and failure rate. METHODS: All 1,078 peroral small-bowel biopsies performed at our department during 1989-99 were studied. In 387 of these, the Watson capsule was used and in the remaining 691 the Storz capsule. Median age of the children was 2.5 years. About one-third of the children were premedicated with the prokinetic drug cisapride and as sedatives alimemazine or diazepam orally. Two-thirds of the children were given metoclopramide along with midazolam intravenously. The biopsies were performed under intermittent fluoroscopy. RESULTS: The median biopsy procedure time was significantly shorter with the Storz capsule (7 min) compared to the Watson capsule (10 min) (P < 0.05). The median fluoroscopy time was 5 sec with the Storz capsule and 8 sec with the Watson capsule (P < 0.01). The failure rate did not differ significantly between the two capsule types: 10.3% (Watson) and 7.7% (Storz). One potential but no serious complication occurred. CONCLUSIONS: Providing that effective sedation is available, small-bowel biopsy with a peroral capsule, and the Storz double-port multibiopsy capsule in particular, is a safe and fast method exposing the child to a minimal radiation dose.

Small bowel capsule biopsy in children: parents' opinions on children's discomfort.

UNLABELLED: This questionnaire study asked the parents of 62 children undergoing small bowel capsule biopsy for their reactions to the discomfort experienced by their children. The children were randomized to receive sedation with midazolam either intravenously or intranasally. With regard to the biopsy procedure the parents of 94% of the children had no objections. The parents of 3% of the children found the biopsy very unpleasant and another 3% suggested that the biopsy should be performed under general anaesthesia. The proportion of parents with negative reactions to the biopsy procedure did not differ significantly between the intravenously and intranasally sedated children. With regard to the sedation given, the parents of 79% of the children did not think that their children were in any discomfort at all. Ten percent of the children had obvious signs of nasal discomfort using the intranasal administration. In the remaining 11% of the children the parents reported various symptoms. CONCLUSION: The vast majority of parents of children undergoing small bowel capsule biopsy found the procedure satisfactory providing that the sedative medication was given intravenously rather than intranasally.

Children with celiac disease express inducible nitric oxide synthase in the small intestine during gluten challenge.

BACKGROUND: Childhood celiac disease in Sweden is presently seen at an incidence of around 1/250 and is thus one of the commonest chronic diseases in children. It has recently been shown that children with untreated celiac disease have increased levels of nitrate/nitrite in the urine, most likely reflecting an increased production of nitric oxide in the inflamed mucosa. Nitric oxide is produced from L-arginine by an inducible or a constitutive nitric oxide synthase. The inducible nitric oxide synthase (iNOS) can be stimulated in various cells by, for instance, inflammatory mediators. The present study has been done to find a possible source of nitric oxide in the small intestine that could result in the increased levels of nitrate/nitrite in the urine in children with active celiac disease. METHODS: Small-intestinal biopsy specimens from children with active celiac disease were labeled with rabbit-anti-human antibodies to iNOS and visualized with fluorescent pig anti-rabbit antibodies. The specimens were then analyzed with confocal microscopy to assess the labeling pattern. RESULTS: In all of seven specimens from children with increased levels of nitrate/nitrite in the urine, we detected antibodies to iNOS, whereas in five of six control specimens--that is, from children with normal nitrate/nitrite levels--we could not detect any iNOS. CONCLUSIONS: Children with active celiac disease have a gluten-induced nitric oxide production in the small intestine reflected by increased urine levels of nitrate/nitrite and iNOS expression in the intestine. We conclude that the increased production of nitric oxide could presumably, directly or indirectly, result in injury of the small-intestinal tissue.

Significantly increased levels of nitric oxide products in urine of children with celiac disease.

BACKGROUND: Celiac disease is characterized by morphologic and functional aberrations of the small intestinal mucosa, i.e., crypt hyperplasia, villous atrophy, infiltration of intraepithelial lymphocytes, and alteration of permeability. Nitric oxide has been shown to affect mucosal permeability after ischemia-reperfusion, but little is known about the regulatory role of nitric oxide in celiac disease. The purpose of this study was to assess nitric oxide production in children with celiac disease and in control subjects. METHODS: The sum of nitrite and nitrate in the urine was measured with a colorimetric method in 137 children with a median age of 3 years, 84 patients and 53 reference children, all of whom underwent a small intestinal biopsy to confirm or overrule suspicion of celiac disease. RESULTS: Median urinary nitrite-nitrate concentration in celiac children was 3323 microM (4147 +/- 1102; mean +/- SEM) at first clinical examination and 2501 microM (2939 +/- 386) after gluten challenge, which was significantly higher than concentrations in reference children (1029 microM; 1174 +/- 116) and in children with celiac disease on a gluten-free diet (882 microM; 1369 +/- 360) (p < 0.0001). CONCLUSIONS: A gluten-containing diet is associated with an increased nitrite-nitrate secretion in the urine in children with celiac disease, presumably as a result of nitric oxide synthase activation and nitric oxide production in the diseased small intestinal mucosa.

[Proposed criteria for diagnosis of celiac disease in children]. / Förslag till kriterier för celiakidiagnos hos barn.

At a seminar arranged in September 1997 by the Swedish Paediatric Working Group for Coeliac Disease, a diagnostic protocol proposed by the working group was approved by a majority of the paediatricians present, representing almost all paediatric units in Sweden. Briefly, a small bowel biopsy is called for in all children, both at presentation and as a control during gluten-free dieting. Subsequent gluten challenge and biopsy are mandatory only in cases of atypical presentation or if the diagnosis is questioned at some future date. Serum antigliadin and anti-endomysial antibody tests are complementary tools. Agreement was also reached regarding the institution of a national coeliac disease registry.