The effects of 1-year gluten withdrawal on bone mass, bone metabolism and nutritional status in newly-diagnosed adult coeliac disease patients.

OBJECTIVES: To evaluate the impact of a 1-year gluten-free diet on bone metabolism and nutritional status in coeliac disease. METHODS: Bone mineral density, serum indices of bone remodelling, clinical and biochemical nutritional assessment were evaluated in 86 consecutive newly-diagnosed, biopsy proven, coeliac disease patients (untreated). A complete reevaluation, including intestinal biopsy, was repeated within 1 year of dietary treatment (treated). RESULTS: Untreated: according to WHO criteria, 34% of patients had a normal bone mineral density, 40% had osteopenia and 26% osteoporosis. Between males and females there were no statistical differences in bone metabolism or in most of the nutritional indices, while, between fertile and postmenopausal women, bone mineral density and several bone metabolism markers were significantly different. Compared to subjects with a normal bone mineral density, osteopenics had higher bone specific alkaline phosphatase (BAP) and Bone-Gla-protein (BGP) values. In patients with a concomitant BAP increase and 25OH vitamin D serum level reduction, bone mineral density and several bone turnover markers were statistically different compared to patients without such a serological pattern. Treated: notwithstanding intestinal biopsy which showed a mucosal recovery in only 57%, gluten-free diet led, even in postmenopausal women, to a significant improvement in bone mineral density, bone metabolism and nutrition, except for folic acid, albumin and pre-albumin serum levels which persisted as abnormal in patients with obdurate mucosal impairment. CONCLUSIONS: Coeliac disease patients are at high risk for developing a low bone mineral density and bone turnover impairment. A gluten-free diet can improve this situation even in postmenopausal women and in patients with incomplete mucosal recovery.

A novel method for detecting IgA endomysial antibodies by using human umbilical vein endothelial cells.

BACKGROUND: Although tissue transglutaminase was recently identified as the main autoantigen recognized by endomysial antibodies in coeliac patients, anti-endomysium antibody detection still persists as the gold standard for coeliac disease screening and diagnosis. OBJECTIVES: (1) To evaluate human umbilical vein cells (HUVEC) as an alternative source of endomysial antigen and to assess their suitability in the diagnosis of coeliac disease. (2) To verify whether tissue transglutaminase is one target antigen eliciting the endomysial antibody fraction of coeliac serum IgA. SETTING: University teaching hospital. PATIENTS AND METHODS: Sera from 123 untreated adults with biopsy-proven coeliac disease and 84 controls (40 healthy and 44 diseased) were assessed by indirect immunofluorescence, using HUVEC on glass slides prepared by cytocentrifugation and permeabilized by using Triton X (0.5%). Indirect immunofluorescence was performed: (1) using coeliac disease serum samples on HUVEC with or without prior incubation with tissue transglutaminase; and (2) incubating both HUVEC and monkey oesophagus with goat anti-guinea pig tissue transglutaminase antibody. RESULTS: All the coeliac patients, who were also positive on monkey oesophagus, showed the typical fluorescent homogeneous cytoplasmic stain on HUVEC. All control sera were negative both on HUVEC and on monkey oesophagus. IgA antibodies did not react with non-permeabilized cells, with intact membrane. Preincubation of coeliac sera with tissue transglutaminase abolished the typical fluorescent pattern. The incubation of anti-tissue transglutaminase antibody with monkey oesophagus and HUVEC resulted in an immunofluorescence staining pattern identical to that obtained with positive coeliac sera. CONCLUSIONS: (1) As a substrate for anti-endomysial antibody, HUVEC may provide the same diagnostic accuracy as monkey oesophagus, thus bypassing economical and ethical problems. The HUVEC antigen reacting with IgA from coeliac disease sera is an intracellular rather than a cell-surface antigen, as IgA antibodies reacted only with permeabilized cells. (2) Pretreatment of untreated coeliac sera with tissue transglutaminase abolished almost completely the specific staining; incubation with anti-tissue transglutaminase antibody elicited the characteristic fluorescent pattern, thus confirming that tissue transglutaminase represents the prominent autoantigen in coeliac disease.

Is human umbilical cord the most suitable substrate for the detection of endomysium antibodies in the screening and follow-up of coeliac disease?

BACKGROUND: Immunoglobulin A (IgA) anti-endomysium antibodies, the most reliable immunological marker for both the screening and follow-up of coeliac disease, need monkey oesophagus as antigenic substrate; this limits their use because of high costs and the exploitation of endangered species. OBJECTIVES: (1) To compare the diagnostic accuracy of anti-endomysium antibodies detected by indirect immunofluorescence on monkey oesophagus and on human umbilical cord; (2) to evaluate their reliability during follow-up in detecting non-compliant patients. PATIENTS: One hundred and four untreated adults with biopsy-proven coeliac disease and 94 controls were investigated. RESULTS: Endomysium antibodies were found in 99 patients (95%) on both substrates, with a specificity, respectively, of 100% and 99% on monkey oesophagus and umbilical cord. One year after gluten withdrawal, out of 47 patients who were investigated, only six presented with complete mucosal recovery: none of these subjects was positive on either substrates, while, among patients with persistent histological alterations, endomysium positivity persisted in only 10 on monkey oesophagus, but in 32 on umbilical cord. Histology (recovery or persistent involvement) was in agreement with endomysium (negative or positive) in 34% on monkey oesophagus, but in 81% on umbilical cord (P < 0.0001). CONCLUSION: Human umbilical cord, with its comparable diagnostic efficiency, could replace monkey tissues, with the advantages of saving both money and monkeys. Moreover, it seems the most suitable substrate in the follow-up, as it enables detection of non-compliant patients with persisting mucosal alterations.

Autoimmune thyroid diseases and coeliac disease.

BACKGROUND: Coeliac disease may be associated with a wide variety of diseases of known or suspected immunological aetiology. OBJECTIVE: To screen for both (a) the prevalence of coeliac disease in adults with autoimmune thyroid diseases, and (b) thyroid impairment among adults with coeliac disease, as compared to sex- and age-matched controls. DESIGN: Prospective cohort study. SETTING: University teaching hospital. PATIENTS: A total of 152 consecutive adults with autoimmune thyroid diseases, 185 consecutive coeliac disease patients (53 newly diagnosed and 132 already on a gluten-free diet) and 170 sex- and age-matched controls. METHODS: Screening for coeliac disease was done by means of IgA anti-endomysium antibodies, detected by indirect immunofluorescence on monkey oesophagus. Patients with positive sera underwent duodenal biopsy for diagnostic confirmation. Thyroid function was assessed by measuring the levels of serum thyroid-stimulating hormone, free T3, free T4, thyroperoxidase and thyroid microsome antibodies. Autoimmune thyroid diseases were classified according to the American Thyroid Association guidelines. RESULTS: Anti-endomysium antibodies were positive in five of 152 autoimmune thyroid disease patients (3.3%) and coeliac disease was histologically confirmed in all: this prevalence is 10-fold higher than expected. Only one patient presented with gastrointestinal complaints, but iron deficiency was found in three and alterations at bone mineralometry in all. The overall prevalence of autoimmune thyroid diseases was significantly higher (38/185, 20.5%) in coeliac patients than in controls (19/170, 11.2%). The prevalence of both hypo- and hyperthyroidism was not different from that of controls, while the prevalence of autoimmune thyroid disease with euthyroidism was 13% in patients and 4.7% in controls. CONCLUSIONS: The association of coeliac disease with autoimmune thyroid disease is not surprising as they share common immunopathogenetic mechanisms. It is advisable to screen autoimmune thyroid disease patients for coeliac disease as there is an increased risk for gluten intolerance. In contrast, thyroid function assessment in coeliac disease patients is probably less justified, although the need for a strict clinical follow-up of those patients with euthyroidism and autoimmune thyroid disease, who could develop overt thyroid impairment, remains an open question.

Prevalence of coeliac disease in primary biliary cirrhosis and of antimitochondrial antibodies in adult coeliac disease patients in Italy.

BACKGROUND: Although an association between primary biliary cirrhosis and coeliac disease has recently been reported in Northern Europe, there are still conflicting data concerning this issue. AIM: To evaluate both the prevalence of coeliac disease in a series of primary biliary cirrhosis patients and that of antimitochondrial antibodies in a series of adult biopsy proven coeliac disease patients from Northern Italy. PATIENTS AND METHODS: A total of 87 primary biliary cirrhosis patients (79 female, 8 male) were screened for both IgA-transglutaminase antibodies and antiendomysium antibodies and, in those with either IgA-transglutaminase antibodies or antiendomysium antibodies positivity, upper endoscopy with distal duodenum biopsy was offered. In those who refused upper endoscopy, the intestinal permeability test with lactulose/mannitol excretion was performed. RESULTS: Antiendomysium antibodies positivity was detected in 3 subjects (3.4%), all of whom had serum IgA-transglutaminase antibodies above the normal range, and fulfilled the diagnosis of coeliac disease. Of 21 other patients with serum IgA-transglutaminase antibodies above the normal range, 17 underwent upper endoscopy which revealed normal duodenum architecture. The remaining 4 patients underwent the lactulose/mannitol excretion test which was within the normal range. Sera from 108 adult coeliac disease patients were tested for antimitochondrial antibodies and positivity was found in 4 patients (3.7%): all had normal liver biochemistry tests, whereas 2 of them also presented thyroid disease. Antibodies directed to the 74-kDa polypeptide of antimitochondrial antibodies were found in 3 out of 4 antimitochondrial antibodies+ve patients. CONCLUSIONS: These results suggest an association between primary biliary cirrhosis and coeliac disease similar to that observed in the Northern European series. In conclusion, screening for coeliac disease with antiendomysium antibodies in primary biliary cirrhosis is justified, and screening for antimitochondrial antibodies is advisable in adult coeliac disease patients.

Do dietary antibodies still play a role in the diagnosis and follow-up of coeliac disease? A comparison among different serological tests.

OBJECTIVE: Comparison between the usefulness of immunological markers and intestinal biopsy in the diagnosis and follow-up of coeliac disease. MATERIALS AND METHODS: Serum antibodies to gliadin, several dietary proteins and endomysium were appraised in 27 patients with biopsy proven coeliac disease, both while untreated and 6-8 months after gluten withdrawal, when an intestinal biopsy was repeated. Forty-six healthy volunteers entered the study as controls. Antibodies to gliadin and dietary proteins were assessed by ELISA, antibodies to endomysium by indirect immunofluorescence using monkey oesophagus as antigen. RESULTS: Mean antibody levels to dietary proteins were significantly higher in untreated patients as compared to controls. Their titers decreased after gluten withdrawal, but a significant difference was found, except for casein, for the IgA class only. However, because of their unlinear and unpredictable behaviour, they showed a poor reliability. Antigliadin antibodies showed higher diagnostic accuracy, although they also produced false-positive and false-negative results. Anti-endomysium antibodies, albeit the more expensive, proved the more reliable, due to their 100% specificity. CONCLUSION: To date, anti-endomysium antibodies are the most reliable marker for coeliac disease: a positivity warrants an intestinal biopsy. The actual role of antibodies to gliadin, cheaper than endomysium, is during follow-up when many determinations are needed. Antibodies to dietary proteins, useful in the pre-endomysium era, only have a historical role.

Helicobacter pylori infection: comparison among four different therapeutic regimens.

Helicobacter pylori is both virulent and pathogenic, yet it is not clear what is the best way to treat the infection. This study compares the ability of 4 regimens of colloidal bismuth subcitrate (CBS) 120 mg q.i.d. for 4 weeks, combined with one or two antibiotics, to eradicate helicobacter pylori and assesses the outcome of eradication on antral gastritis and on symptoms of non-ulcer dyspepsia in 140 consecutive subjects (44 duodenal ulcers and 96 non ulcer dyspepsia). Endoscopy with antral biopsies was repeated in all patients before (T0) and one month after stopping treatments (T2) while duodenal ulcers were endoscoped also at the completion of treatments (T1). The four regimens showed similar eradication and ulcer healing rates (p = ns). After treatments (T1), about 60% of dyspeptic patients achieved a subjective improvement, not significant despite therapeutic regimen, and persisting at T2. Antral gastritis significantly improved after treatments (p less than 0.0001), even with the persistence of the infection (p less than 0.001). The 4 regimens are relatively safe, as no abnormality in laboratory assessment was found, albeit the frequency of side effects (most of whom tinidazole related) and the difficulty of the schedules (6-10 tablets/day) may limit patient compliance.

Indirect immunofluorescence for of anti-jejunum antibody detection in celiac disease: comparison among different antigenic substrates.

BACKGROUND: Although anti-endomysium antibodies (EmA) are the most reliable serological markers of celiac disease (CD), there is a need for low-cost methods for screening programs, as clinically silent disease is increasingly recognized. AIM: To evaluate the suitability of monkey, rat and rabbit jejunum as a substrate for the determination of anti-jejunun antibodies (JAB) in CD. METHODS: JAB of IgA class were detected by indirect immunofluorescence on frozen sections of jejunum from monkeys, white rats and domestic rabbits. Sera from 61 untreated adults with biopsy-proven CD and EmA positivity in 57 out of 61 entered the study as true positives, while sera from 60 controls were considered as true negatives. RESULTS: The sections of monkey jejunum showed the characteristic pattern of elongated villous fluorescence, a ring-like positivity of the cryptal basement membrane, an endomysium-like fluorescence along the smooth muscle layers in the tunica muscolaris, while pericryptal fluorescence was not so evident on rat and rabbit jejunum. As compared to EmA positivity, the prevalence of JAB on monkey, rat and rabbit tissues was respectively 57/57, 54/57, 52/57. Two sera among 4 Ema negatives proved positive for JAB. No false positivity resulted from EmA and JAB on monkey jejunum, while a lower specificity was found for JAB on rat and rabbit substrates. CONCLUSIONS: Although monkey, rat and rabbit small intestine appeared to be a suitable alternative substrate for determination of IgA-JAB, because of its lower cost and higher availability, it cannot replace monkey oesophagus, and be recommended for wide use.

A twelve-month follow-up after Helicobacter pylori eradication. A clinical and histological evaluation.

To evaluate a twelve-month effect of Helicobacter pylori eradication, 258 consecutive out-patients with H. pylori related active duodenal ulcer were given a ten-day eradicating treatment. After healing no maintenance antiulcer medication was given. On entering the study and then 2, 6 and 12 months after the completion of therapy patients were scored for symptoms and underwent endoscopy to assess the presence of duodenal ulcer and to score antrum and corpus gastritis. Statistical analysis was performed by means of the chi 2 test. Histological eradication, defined as the inability to detect H. pylori six months after the completion of the eradication course, was proved in 85 subjects while the 123 non-eradicated ones were considered as the control group. Ulcer relapse rate and ulcer-like symptoms were significantly less frequent among eradicated than non eradicated throughout the follow-up. As compared to non eradicated, gastritis significantly improved among eradicated in both antrum and corpus. H. pylori eradication may be recommended since, by reducing ulcer relapse rate and related symptoms, there is no need for further antiulcer maintenance therapy with a significant drop in socioeconomic costs.

[Antiendomysium antibodies in the diagnosis of celiac disease in the adult]. / Gli anticorpi anti-endomisio nella diagnosi di malattia celiaca dell'adulto.

The identification of anti-endomysial antibodies in the serum of coeliac patients has provided a useful diagnostic tool to be used together with biopsy. In this study the presence of these antibodies was evaluated in a population of adult coeliac patients. 92.86% sensitivity and 100% specificity were obtained together with 98.68% diagnostic accuracy. The antibody titer tends to diminish progressively and become negative in patients who adhere strictly to their diet. Anti-endomysial antibodies may therefore be used at both the screening stage as well as during follow-up and they allow an objective assessment of diet compliance to be made.

[28 cases of malabsorption syndromes with villopathy]. / Osservazioni per 28 casi di sindromi da malassorbimento con villopatia

A personal series of 28 cases of malabsorption with villopathy (22 Gee, 1 Whipple, 1 alpha-chain, 1 hypogammaglobulinaemia, 3 not yet diagnosed) is presented. The response to a gluten-free diet is the essential clue to diagnosis. Where sensitivity is not found, diagnosis becomes difficult and requires careful immunological, histopathological and parasitological investigation, which is not always conclusive. The main features of the series are indicated, along with the criteria employed in the diagnosis of some unusual forms.

Indirect immunofluorescence for anti-jejunum antibody detection in celiac disease: comparison among different antigenic substrates.

BACKGROUND: Although anti-endomysium antibodies (EmA) are the most reliable serological markers of celiac disease (CD), there is a need for low-cost methods for screening programs, as clinically silent disease is increasingly recognized. AIM: To evaluate the suitability of monkey, rat and rabbit jejunum as a substrate for the determination of anti-jejunum antibodies (JAB) in CD. METHODS: JAB of IgA class were detected by indirect immunofluorescence on frozen sections of jejunum from monkeys, white rats and domestic rabbits. Sera from 61 untreated adults with biopsy-proven CD and EmA positivity in 57 out of 61 entered the study as true positives, while sera from 60 controls were considered as true negatives. RESULTS: The sections of monkey jejunum showed the characteristic pattern of elongated villous fluorescence, a ring-like positivity of the cryptal basement membrane, an endomysium-like fluorescence along the smooth muscle layers in the tunica muscularis, while pericryptal fluorescence was not so evident on rat and rabbit jejunum. As compared to EmA positivity, the prevalence of JAB on monkey, rat and rabbit tissues was respectively 57/57, 54/57, 52/57. Two sera among 4 Ema negatives proved positive for JAB. No false positivity resulted from EmA and JAB on monkey jejunum, while a lower specificity was found for JAB on rat and rabbit substrates. CONCLUSIONS: Although monkey, rat and rabbit small intestine appeared to be a suitable alternative substrate for determination of IgA-JAB, because of its lower cost and higher availability, it cannot replace monkey oesophagus, and be recommended for wide use.

Long-term ranitidine treatment for the maintenance of duodenal ulcer healing.

The purpose of the present trial was to verify the efficacy and safety of long-term ranitidine treatment (150 mg at bedtime for 1 year) for the maintenance of duodenal ulcer healing in 22 patients following a successful short-term course of therapy with ranitidine at the full dose of 300 mg per day. Of the 16 patients who completed the trial - there were 6 drop-outs - 4 suffered relapses during the year of treatment (25% cumulative recurrence rate), while remission persisted in the remaining 12 patients (75%). Biochemical tests revealed no statistically significant differences in mean fasting serum pepsinogen and trypsinogen as compared to mean basal values. Mean fasting serum gastrin showed a statistically significant rise from 156 +/- 27 S.D. to 258 +/- 110 S.D. pg/ml (p less than 0.01) only at the 12th month of therapy and rapidly returned to normal (162 +/- 34 S.D.) as soon as therapy was discontinued. No side-effects of any consequence were observed.

Diagnostic usefulness of serum group I pepsinogen determination.

In order to evaluate its clinical usefulness, serum pepsinogen I level was measured in a prospective study in unselected patients affected by endoscopically and histologically confirmed gastric or duodenal diseases. The mean level in controls was 63 +/- 26 ng/ml (M +/- SD) with no statistical difference between males and females, while it was significantly higher in smokers than in non-smokers (respectively 69 +/- 25 and 56 +/- 25 ng/ml). On the average in gastric ulcer patients it overlapped with controls (69 +/- 34 ng/ml), but in prepyloric ulcers its value was higher (81 +/- 45 ng/ml) than that found in ulcer of the gastric corpus (66 +/- 30 ng/ml). Serum pepsinogen I level was significantly higher in duodenal ulcer patients (81 +/- 33 ng/ml), in males as compared to females and in smokers as compared to non-smokers (respectively 91 +/- 32 and 67 +/- 26 ng/ml). Higher than normal values were found in one subject affected by the Zollinger-Ellison syndrome, and in patients with severe renal failure. Low and very low levels were found after partial and total gastrectomies and in A type atrophic gastritis. In the case of duodenal ulcer, serum pepsinogen I determination showed a 16 p. 100 sensitivity and a 96 p. 100 specificity, while for atrophic gastritis it showed an 87 p. 100 sensitivity and a 100 p. 100 specificity. It is concluded that, at present, the most important clinical application seems to be its screening value in the detection of atrophic gastritis and consequently its potential use to detect populations at increased risk for gastric cancer.

Serum group I pepsinogens level in cystic fibrosis.

Fasting serum pepsinogen 1 level was determined by radioimmunoassay in 30 patients with cystic fibrosis and in on equal number of age-matched healthy children. Serum pepsinogen 1 basal levels were significantly higher (49 +/- 18 ng/ml; p less than 0.01) in cystic fibrosis patients than in controls (38 +/- 12 ng/ml). The increased pepsinogen 1 level did not correlate with the levels of Po2 and Pco2 tensions, fat balance or basal and maximum acid outputs. It is concluded that the mechanisms which lead to a rise of serum pepsinogen 1 in cystic fibrosis are unknown. However these findings could provide useful information with regard to the biology of a disease whose physiopathology is still unknown.

[Clinical characteristics of 153 patients with Crohn's disease. Presentation of a Turin case series]. / Caratteristiche cliniche di 153 pazienti affetti da malattia di Crohn. Presentazione di una casistica torinese.

This clinical and epidemiological retrospective study of 153 Italian Crohn's disease patients, surveyed between 1965 and 1988 took into account the following features: male to female ratio; region of origin; familiarity; age at onset; anatomical site of lesions; symptoms at onset; diagnostic delay; local and general complications; relapses; admissions; surgery and mortality rates. The clinical patterns of 67 patients surveyed between 1965 and 1977 (group A) were compared with those of 86 patients observed from 1978 to 1988 (group B). Overall results agreed with those of the literature, except for a male prevalence and a longer diagnostic delay. As compared to group A, group B showed: a) a higher number of females; b) a statistically significant increase (p less than 0.001) of patients from Southern Italy, thus supporting the hypothesis of a role of environmental factors in the onset of the disease; c) a reduced surgery rate, in agreement with the general trend of a more cautious surgical approach in Crohn's disease.

[Evaluation of the antigliadin antibody titer in adult celiac disease]. / Valutazione del titolo degli anticorpi antigliadina nella malattia celiaca dell'adulto.

Serum gliadin antibodies of the IgA and IgG isotypes were assessed with an enzyme-linked immunosorbent assay technique in adults during different phases of coeliac disease (30 on a gluten-containing diet and 24 on a gluten-free diet), in patients with other gastrointestinal disorders (Crohn's disease, ulcerative colitis) and in healthy controls. Significantly higher antibody values were found in 70% of coeliacs on a gluten-containing diet, compared with the findings in the healthy controls and with those in the same subjects after one year on a gluten-free diet. Serum antibodies of the IgA class were associated with severe small intestine villous atrophy and were found exclusively in coeliac disease. Gliadin antibodies of IgG class were less disease-specific and were occasionally detected in sera from patients with gastrointestinal diseases and in 6% of healthy controls.

Tumor necrosis factor/cachectin in Crohn's disease. Relation of serum concentration to disease activity.

Inflammatory mediators seem to be involved in the pathogenesis of Crohn's disease. Tumor necrosis factor is a primary mediator of inflammatory responses which causes metabolic effects related to tissue wasting. The aims of this study were to establish the presence of tumor necrosis factor in Crohn's disease patients, to determine of its serum levels reflect disease activity and to examine the relationship if this cytokine with other assessments of the activity of the disease. Serum concentration of tumor necrosis factor, measured with a biological assay, was significantly raised in 56 Crohn's disease patients (201 determinations) as compared with 44 controls (P < 0.0001). Patients with inactive disease had significantly lower tumor necrosis factor levels (3.58 +/- 0.55 ng/mL) as compared to patients with active disease (8.17 +/- 1.01 ng/mL). There was a significant correlation between serum tumor necrosis factor concentration and disease activity (r = 0.237, P < 0.002). Higher tumor necrosis factor levels were detected in patients with colonic involvement (ileocolitis and colitis) as compared with ileal localizations, and the difference was significant (t = 2.16, P < 0.05). Besides, it correlated negatively with albumin, haemoglobin and cholesterol.