Assessing mucosal recovery in celiac disease - Time to diagnosis and histological severity as determining factors.

Study background and objectives: There is great disparity in mucosal recovery among celiac patients on a gluten-free diet. We report a study to identify associated factors. METHODS: Celiac patient cases were collected that had positive celiac serology and villous atrophy at diagnosis, and had undergone a control biopsy after at least 12 months of follow-up. RESULTS: We included 70 celiac patients. They had experienced symptoms for 9.05 ± 9.48 years before being diagnosed. After follow-up for 2.93 ± 1.94 years, 34.3 % had complete mucosal recovery and 57.1 % had partial mucosal recovery. In the comparative analysis we found no relationship between mucosal recovery and sex, age, clinical manifestations or follow-up time from diagnosis to second biopsy. Time with clinical manifestations before diagnosis was associated with a worse outcome: 2.64 years in patients with full recovery, 4.61 years in patients with partial recovery, and 14.26 years in patients with persistent villous atrophy. Higher transglutaminase antibody titers both at diagnosis and during follow-up were associated with poorer histologic outcomes. We observed higher mucosal recovey rates in patients with mild atrophy versus severe atrophy at diagnosis. CONCLUSIONS: In spite of gluten-free diet a significant proportion of patients have persistent histologic changes. Time with clinical manifestations before diagnosis is key for histological severity and recovery.

Relación de los factores demográficos e higiénico-dietéticos con la patología hallada en las colonoscopias ambulatorias realizadas en un centro del Servicio Castellano y Leonés de Salud / Relationship of demographic and dietary hygiene factors with the pathology found in outpatient colonoscopies performed in a Castilla y León Health Service center

Introducción: el cáncer colorrectal (CCR) es un tumor muy frecuente en términos de incidencia y mortalidad. Su patogenia se ha relacionado con diversos factores ambientales y hereditarios. Objetivos: analizar la asociación de edad, sexo y factores dietéticos con el diagnóstico de adenomas y CCR. Métodos: se realizó un estudio descriptivo prospectivo con los pacientes del Área Sanitaria de León que se sometieron a una colonoscopia ambulatoria entre 09/09/2012 y 30/06/2013. Mediante un formulario autoadministrado se recogieron datos sociodemográficos, tóxicos y dietéticos usando un cuestionario alimentario de frecuencia semicuantitativo. Se analizaron las diferencias en el diagnóstico según los datos sociodemográficos e higiénico-dietéticos, con análisis multivariante mediante regresión logística por pasos hacia delante. Resultados: se recogieron datos de 1390 pacientes cuya edad media fue de 57 (15) años; de ellos, el 47,8 % eran varones. Se diagnosticaron CCR en el 5 % de los pacientes y pólipos en el 20,4 % (9,4 % de adenomas de alto riesgo (AAR)). El hallazgo de pólipos y AAR fue más frecuente en los varones (26,9 % vs. 14,5 % y 12,6 % vs. 6,3 %, respectivamente (p < 0,001)). La edad media fue significativamente superior en los pacientes que presentaban pólipos (56.51 (15.45) vs. 63.22 (12.69) años; p < 0,001). En la población que refirió un consumo diario de carnes procesadas se duplicaba la proporción de pólipos detectados (2,9 % vs. 6,7 %; p = 0,02). Aquellos pacientes que consumían alcohol diariamente tenían mayor incidencia de pólipos frente al consumo ocasional y los abstemios (32 % vs. 20 % vs. 18,6 %; p = 0,002). Conclusiones: la edad se relacionaba con un mayor riesgo de pólipos, AAR y CCR. Los varones también tenían más riesgo de pólipos y AAR. El consumo de alcohol, carnes rojas y procesadas incrementaba el riesgo de pólipos. (AU)

Background: colorectal cancer (CRC) is one of the most frequent tumors in terms of incidence and mortality. Several elements, both inherited and environmental, have been related with its pathogenesis. Aims: to analyze the influence of age, gender and nutritional factors on the diagnosis of colonic polyps and CRC. Methods: a prospective, descriptive study over outpatients from the Health Area of León who took a colonoscopy between 09/09/2012 and 06/30/2013. Patients were asked to fill a semiquantitative food frecuency questionnaire with data such a sociodemographic, toxic and dietetic facts. Differences in diagnosis according to sociodemographic and hygiene-dietetic data were analyzed with a multivariate analysis by forward stepwise logistic regression. Results: data were collected from 1390 patients. Mean age was 57.88 (15.17) years and 47.8 % were male. CRC was diagnosed in 5 % of colonoscopies, and polyps in 20.4 %, with 9.4 % of them being HRA. Risk of polyps and HRA was higher in males (26.9 % vs 14.5 %) and (12.6 % vs 6.3 %), respectively (p < 0.001). Mean age was significantly higher in patients who presented polyps (56.51 (15.45) vs 63.22 (12.69) years; p < 0.001). Among the group who reported intake of smoked and salted food, the risk of polyps doubled (2.9 % vs 6.7 %, p = 0.002). In relation to alcohol intake we found that subjects with daily alcohol consumption showed a higher incidence of polyps whe compared to occasional drinkers and teetotallers (32 % vs 20 % vs 18.6 %, p = 0.002) Conclusions: age correlated with higher risk of polyps, HRA and CRC. Moreover, male gender also was associated with a high risk of polyps and HRA. Alcohol and red and processed meat intake increased polyp risk. (AU)

[Relationship of demographic and dietary hygiene factors with the pathology found in outpatient colonoscopies performed in a Castilla y León Health Service center]. / Relación de los factores demográficos e higiénico-dietéticos con la patología hallada en las colonoscopias ambulatorias realizadas en un centro del Servicio Castellano y Leonés de Salud.

Introduction: Background: colorectal cancer (CRC) is one of the most frequent tumors in terms of incidence and mortality. Several elements, both inherited and environmental, have been related with its pathogenesis. Aims: to analyze the influence of age, gender and nutritional factors on the diagnosis of colonic polyps and CRC. Methods: a prospective, descriptive study over outpatients from the Health Area of León who took a colonoscopy between 09/09/2012 and 06/30/2013. Patients were asked to fill a semiquantitative food frecuency questionnaire with data such a sociodemographic, toxic and dietetic facts. Differences in diagnosis according to sociodemographic and hygiene-dietetic data were analyzed with a multivariate analysis by forward stepwise logistic regression. Results: data were collected from 1390 patients. Mean age was 57.88 (15.17) years and 47.8 % were male. CRC was diagnosed in 5 % of colonoscopies, and polyps in 20.4 %, with 9.4 % of them being HRA. Risk of polyps and HRA was higher in males (26.9 % vs 14.5 %) and (12.6 % vs 6.3 %), respectively (p < 0.001). Mean age was significantly higher in patients who presented polyps (56.51 (15.45) vs 63.22 (12.69) years; p < 0.001). Among the group who reported intake of smoked and salted food, the risk of polyps doubled (2.9 % vs 6.7 %, p = 0.002). In relation to alcohol intake we found that subjects with daily alcohol consumption showed a higher incidence of polyps whe compared to occasional drinkers and teetotallers (32 % vs 20 % vs 18.6 %, p = 0.002) Conclusions: age correlated with higher risk of polyps, HRA and CRC. Moreover, male gender also was associated with a high risk of polyps and HRA. Alcohol and red and processed meat intake increased polyp risk.

Introducción: Introducción: el cáncer colorrectal (CCR) es un tumor muy frecuente en términos de incidencia y mortalidad. Su patogenia se ha relacionado con diversos factores ambientales y hereditarios. Objetivos: analizar la asociación de edad, sexo y factores dietéticos con el diagnóstico de adenomas y CCR. Métodos: se realizó un estudio descriptivo prospectivo con los pacientes del Área Sanitaria de León que se sometieron a una colonoscopia ambulatoria entre 09/09/2012 y 30/06/2013. Mediante un formulario autoadministrado se recogieron datos sociodemográficos, tóxicos y dietéticos usando un cuestionario alimentario de frecuencia semicuantitativo. Se analizaron las diferencias en el diagnóstico según los datos sociodemográficos e higiénico-dietéticos, con análisis multivariante mediante regresión logística por pasos hacia delante. Resultados: se recogieron datos de 1390 pacientes cuya edad media fue de 57 (15) años; de ellos, el 47,8 % eran varones. Se diagnosticaron CCR en el 5 % de los pacientes y pólipos en el 20,4 % (9,4 % de adenomas de alto riesgo (AAR)). El hallazgo de pólipos y AAR fue más frecuente en los varones (26,9 % vs. 14,5 % y 12,6 % vs. 6,3 %, respectivamente (p < 0,001)). La edad media fue significativamente superior en los pacientes que presentaban pólipos (56.51 (15.45) vs. 63.22 (12.69) años; p < 0,001). En la población que refirió un consumo diario de carnes procesadas se duplicaba la proporción de pólipos detectados (2,9 % vs. 6,7 %; p = 0,02). Aquellos pacientes que consumían alcohol diariamente tenían mayor incidencia de pólipos frente al consumo ocasional y los abstemios (32 % vs. 20 % vs. 18,6 %; p = 0,002). Conclusiones: la edad se relacionaba con un mayor riesgo de pólipos, AAR y CCR. Los varones también tenían más riesgo de pólipos y AAR. El consumo de alcohol, carnes rojas y procesadas incrementaba el riesgo de pólipos.

Linfangiectasia intestinal primaria: una enfermedad rara como causa de enteropatía pierde-proteínas / Primary intestinal lymphangiectasia: a rare disease as a cause of protein-losing enteropathy

La linfangiectasia intestinal primaria es un trastorno raro asociado a una enteropatía pierde-proteínas. Las principales manifestaciones son las derivadas de la hipoalbuminemia. Para lograr el diagnóstico se necesita la imagen endoscópica típica de la linfangiectasia intestinal y el aumento de las cifras de alfa-1-antitripsina en las heces de 24 horas. El tratamiento es básicamente dietético. (AU)

Primary intestinal lymphangiectasia: a rare disease as a cause of protein-losing enteropathy.

Primary intestinal lymphangiectasia is a rare disorder associated with protein-losing enteropathy. The main manifestations are those resulting from hypoalbuminemia. Diagnosis requires the typical endoscopic image of intestinal lymphangiectasia and increased 24-hour fecal alpha-1-antitrypsin clearance. Treatment is basically dietary.

Hallazgos de la endoscopia digestiva alta en pacientes con obesidad mórbida candidatos a cirugía bariátrica / Upper endoscopy findings in obese morbid patients candidates for bariatric surgery

INTRODUCCIÓN: El índice de masa corporal se ha relacionado con la presencia de patología digestiva. El objetivo del estudio fue analizar los hallazgos endoscópicos y la histología gástrica de pacientes con obesidad mórbida candidatos a cirugía bariátrica en nuestro medio. MÉTODOS: Se incluyeron de manera retrospectiva los pacientes intervenidos de cirugía bariátrica en el Hospital de León desde marzo 2005 hasta abril 2013. Se recogieron los hallazgos de la endoscopia digestiva alta y la histología antral. Se estudió si el índice de masa corporal (IMC) estaba relacionado con los hallazgos de la gastroscopia o la presencia de Helicobacter pylori. RESULTADOS: Se incluyeron 194 pacientes. El 48,7 y el 78,9% de los pacientes presentaron alguna alteración en la endoscopia o en la biopsia antral, respectivamente. Tres pacientes presentaron úlcera gástrica péptica, demorándose la intervención hasta la curación. El 63,9% de los pacientes presentaron infección por H. pylori. La presencia de H. pylori y los hallazgos endoscópicos no se relacionaron con el IMC. CONCLUSIÓN: La patología gastroesofágica es frecuente en obesos mórbidos, y aproximadamente la mitad de los pacientes tenían algún tipo de alteración en la endoscopia. La realización de una gastroscopia e investigar la infección por H. pylori previa a la cirugía es necesario con el fin de descartar patología potencialmente susceptible de contraindicar o demorar la intervención

INTRODUCTION: Body mass index has been associated with the presence and severity of various gastrointestinal symptoms. The aim of the study was to analyze the endoscopic findings and gastric histology of morbidly obese candidates for bariatric surgery. METHODS: We retrospectively included patients undergoing bariatric surgery at the Hospital de León from March 2005 to April 2013. The findings of upper gastrointestinal endoscopy and antral histology were collected. The relationship of body mass index (BMI) with gastroscopy findings and the presence ofHelicobacter pylori were assessed. RESULTS: A total of 194 patients were included. An abnormality on endoscopy or antral biopsy was found in 48.7% and 78.9% of the patients, respectively. Three patients had gastric peptic ulcer, and consequently the intervention was postponed until healing. H. pylori infection was found in 63.9% of the patients. The presence of H. pylori and endoscopic findings were not related to BMI. CONCLUSION: Gastroesophageal disease is common in morbidly obese patients and approximately half of the patients had some kind of alteration on endoscopy. Gastroscopy and H. pylori testing prior to surgery is required to rule out disease that could delay or contraindicate surgery

Factores asociados al nivel de limpieza colónica medido mediante la escala de Boston en la práctica clínica habitual / Factors associated with colon cleansing measured with the Boston scale in routine clinical practice

INTRODUCCIÓN La escala de Boston es una herramienta útil para estandarizar el nivel de preparación en la colonoscopia. El objetivo del trabajo fue analizar el grado de limpieza de la colonoscopia y los factores asociados a este en la práctica clínica habitual. MATERIAL Y MÉTODOS: Se incluyeron las colonoscopias realizadas desde enero hasta junio de 2013. Los motivos de exclusión fueron: edad < 15 años, antecedentes de cirugía colónica, enfermedad inflamatoria intestinal o hemorragia digestiva activa. Los parámetros estudiados en relación con el grado de limpieza (mediante la escala de Boston) fueron: la edad, el sexo, la indicación, el turno de la exploración (mañana o tarde), la procedencia (ambulante o ingresado) y los hallazgos encontrados. RESULTADOS: Se analizaron 947 exploraciones, excluyéndose 297. El 5,8% (38/650) de las exploraciones fueron incompletas, el 50% por falta de preparación. La edad media fue de 61,27 años (DS: 16,1), siendo el 51,8% mujeres. La distribución del nivel de preparación fue: 0-3 6,3%; 4-5 12,6%; 6-7 30,6%; 8-9 50,4%, siendo la media 7,04 (DS: 2,03). En el análisis multivariante los factores asociados a una mejor preparación que resultaron estadísticamente significativos fueron: una edad menor, el turno de tarde y el régimen ambulatorio. El porcentaje de pólipos en pacientes con una escala de Boston 5 fue de 10%, frente al 27,8% en pacientes con una puntuación > 5 (p = 0,014). CONCLUSIÓN: En la práctica clínica se obtiene un grado de preparación aceptable en el 80% de los pacientes. Los pacientes con más edad, aquellos que se realizan la colonoscopia de mañana o estando ingresados serían candidatos a medidas para mejorar el grado de preparación

INTRODUCTION: The Boston scale is useful to standardize colon cleansing at colonoscopy. The aim of this study was to analyze the degree of preparation before colonoscopy and the factors associated with cleansing in routine clinical practice. MATERIAL AND METHODS: We included colonoscopies performed from January to June 2013. Exclusion criteria were age < 15 years, a history of colon surgery, inflammatory bowel disease, and active gastrointestinal bleeding. The standard preparation was CitraFleet(R). The parameters related to the degree of bowel cleansing (using the Boston scale) were age, sex, indication, colonoscopy shift (morning or afternoon), patient origin (outpatient or hospitalized), and colonoscopy findings. RESULTS We analyzed 947 colonoscopies, with exclusion of 297. A total of 5.8% (38/ 650) of the colonoscopies were incomplete, 50% due to lack of preparation. The mean age of the patients was 61.27 years (SD: 16.1), and 51.8% were women. The distribution of the Boston scale was 0-3 in 6.3%, 4-5 in 12.6%, 6-7 in 30.6%, and 8-9 in 50.4%, with a mean 7.04 (SD: 2.03). On multivariate analysis, the factors statistically associated with better preparation were younger age, afternoon colonoscopy and the outpatient setting. The percentage of polyps in patients with a Boston scale score ≤ 5 was 10% compared with 27.8% in patients with a score > 5 (P = .014). CONCLUSION: In clinical practice, 80% of patients had an acceptable level of preparation. Older patients, those undergoing colonoscopy in the morning and hospitalized patients would be candidates for measures to improve the degree of colonic preparation

[Factors associated with colon cleansing measured with the Boston scale in routine clinical practice]. / Factores asociados al nivel de limpieza colónica medido mediante la escala de Boston en la práctica clínica habitual.

INTRODUCTION: The Boston scale is useful to standardize colon cleansing at colonoscopy. The aim of this study was to analyze the degree of preparation before colonoscopy and the factors associated with cleansing in routine clinical practice. MATERIAL AND METHODS: We included colonoscopies performed from January to June 2013. Exclusion criteria were age <15 years, a history of colon surgery, inflammatory bowel disease, and active gastrointestinal bleeding. The standard preparation was CitraFleet. The parameters related to the degree of bowel cleansing (using the Boston scale) were age, sex, indication, colonoscopy shift (morning or afternoon), patient origin (outpatient or hospitalized), and colonoscopy findings. RESULTS: We analyzed 947 colonoscopies, with exclusion of 297. A total of 5.8% (38/650) of the colonoscopies were incomplete, 50% due to lack of preparation. The mean age of the patients was 61.27 years (SD: 16.1), and 51.8% were women. The distribution of the Boston scale was 0-3 in 6.3%, 4-5 in 12.6%, 6-7 in 30.6%, and 8-9 in 50.4%, with a mean 7.04 (SD: 2.03). On multivariate analysis, the factors statistically associated with better preparation were younger age, afternoon colonoscopy and the outpatient setting. The percentage of polyps in patients with a Boston scale score ≤5 was 10% compared with 27.8% in patients with a score > 5 (P=.014). CONCLUSION: In clinical practice, 80% of patients had an acceptable level of preparation. Older patients, those undergoing colonoscopy in the morning and hospitalized patients would be candidates for measures to improve the degree of colonic preparation.

[Upper endoscopy findings in obese morbid patients candidates for bariatric surgery]. / Hallazgos de la endoscopia digestiva alta en pacientes con obesidad mórbida candidatos a cirugía bariátrica.

INTRODUCTION: Body mass index has been associated with the presence and severity of various gastrointestinal symptoms. The aim of the study was to analyze the endoscopic findings and gastric histology of morbidly obese candidates for bariatric surgery. METHODS: We retrospectively included patients undergoing bariatric surgery at the Hospital de León from March 2005 to April 2013. The findings of upper gastrointestinal endoscopy and antral histology were collected. The relationship of body mass index (BMI) with gastroscopy findings and the presence of Helicobacter pylori were assessed. RESULTS: A total of 194 patients were included. An abnormality on endoscopy or antral biopsy was found in 48.7% and 78.9% of the patients, respectively. Three patients had gastric peptic ulcer, and consequently the intervention was postponed until healing. H.pylori infection was found in 63.9% of the patients. The presence of H.pylori and endoscopic findings were not related to BMI. CONCLUSION: Gastroesophageal disease is common in morbidly obese patients and approximately half of the patients had some kind of alteration on endoscopy. Gastroscopy and H.pylori testing prior to surgery is required to rule out disease that could delay or contraindicate surgery.

Preparation of inocula for experimental infection of blood with Streptococcus pneumoniae.

Experimental infections of either cells or animals require the preparation of good quality inocula. Unfortunately, the important pulmonary pathogen Streptococcus pneumoniae is a fastidious microorganism that suffers an autolysis process when cultured in vitro. Supplementation of Todd-Hewitt broth with a biological buffer (20 mM Tris-HCl, pH = 7.8) promotes a six hours delay in the beginning of the autolysis process. Additional improvements include washing bacteria before freezing, avoiding manipulations after thawing, and the use of glycerol (<18%) as a cryoprotectant, instead of reagents like skimmed milk that may affect cell cultures. With the proposed protocol >70% of the frozen bacteria was viable after 28 weeks at -80 °C, and aliquots were highly homogeneous. We have tested their utility in a whole blood infection model and have found that human plasma exhibits a higher microbicidal activity than whole blood, a result that we have not found previously reported. Additionally, we have also observed significant variations in the antimicrobial activity against different strains, which might be related to their virulence.•Media culture buffering extends S. pneumoniae viability for 6 h.•Washing before freezing of single use aliquots minimizes manipulation after thawing.•Experimental infection with the frozen inocula has shown that plasma has higher bactericidal activity than blood.

Características clínico-patológicas de los perineuriomas colónicos / Clinicopathologic features of colonic perineuriomas

Los perineuriomas intestinales son lesiones poco frecuentes del tracto gastrointestinal. En este estudio presentamos una serie de 9 casos hallados en la mucosa colónica y analizados desde el punto de vista clínico-patológico e inmunohistoquímico. De ellos, 5 fueron mujeres y 4 hombres con edades medias de 59,5 y 64 años, respectivamente. Todas las lesiones eran de un tamaño inferior a 1 cm y tuvieron una localización intramucosa, predominando las situadas en el colon distal. Las técnicas imnunohistoquímicas para Glut-1, claudina-1 y EMA fueron de gran utilidad para determinar la naturaleza de estas lesiones (AU)

Intestinal perineuriomas are uncommon tumors of the gastrointestinal tract. In thisstudy, we analyzed the clinicopathologic and immunohistochemical features of nine colonic perineuriomas. Five patients were women and four were men (median age 59.5 years and64 years, respectively). All lesions were smaller than 1 cm and were located intramucosally, mainly in the distal colon. Immunohistochemical techniques for Glut-1, claudin-1 and EMA were especially useful in characterizing these lesions (AU)

[Clinicopathologic features of colonic perineuriomas]. / Características clínico-patológicas de los perineuriomas colónicos.

Intestinal perineuriomas are uncommon tumors of the gastrointestinal tract. In this study, we analyzed the clinicopathologic and immunohistochemical features of nine colonic perineuriomas. Five patients were women and four were men (median age 59.5 years and 64 years, respectively). All lesions were smaller than 1cm and were located intramucosally, mainly in the distal colon. Immunohistochemical techniques for Glut-1, claudin-1 and EMA were especially useful in characterizing these lesions.

Anemia ferropénica refractaria e intolerancia al gluten: respuesta a la dieta sin gluten / Refractory iron-deficiency anemia and gluten intolerance - Response to gluten-free diet

Introducción: la anemia ferropénica refractaria presenta un origen multifactorial, relacionado con diversas enfermedades digestivas, siendo las más frecuentes la enfermedad celiaca con malabsorción y la EII junto con la intolerancia al gluten aislada. Objetivos: determinar la prevalencia de marcadores serológicos, genéticos e histológicos de intolerancia al gluten y analizar la respuesta a la retirada del gluten de la dieta en estos pacientes. Métodos: se incluyeron de forma prospectiva y consecutiva una serie de pacientes con anemia refractaria. Se les aplicó un protocolo consistente en determinación marcadores serológicos (TGt-2), genéticos (HLA-DQ2/DQ8) e histológicos de enfermedad celíaca. Todos siguieron una dieta sin gluten durante una mediana de 3,6 años. Se interpretó como respuesta positiva la desaparición mantenida de la anemia durante el seguimiento. Resultados: se estudiaron 98 pacientes (84% mujeres) con una edad media de 54 años. Los ac. anti-TGt2 fueron positivos en el 5% de los casos. Un total de 67 casos (68%) presentaban el haplotipo HLA-DQ2 o DQ8 (+). Encontramos atrofia vellositaria (Marsh III) en el 13% de los casos y patrón inflamatorio (Marsh I o II) en el 13%. Los 72 casos restantes (74%) no presentaban alteraciones histológicas duodenales. Se compararon la edad, el tiempo de evolución de la anemia, número de transfusiones, número de dosis de hierro parenteral y tiempo en dieta sin gluten, en función de la presencia o no de atrofia vellositaria y de la positividad para el HLA-DQ2/8, sin encontrar diferencias significativas en ninguna de las variables analizadas. La respuesta fue positiva en el 92% de los casos. Conclusiones: la enfermedad celiaca con atrofia vellositaria es causa poco frecuente de anemia refractaria. Las formas de intolerancia al gluten sin lesión histológica asociada, representan cerca del 75% de los casos y desempeñan, por lo tanto, un papel importante en su aparición(AU)

Introduction: refractory iron-deficiency anemia has a multifactorial origin related to various gastrointestinal conditions, with celiac disease plus malabsorption and IBD together with isolated gluten intolerance being most common. Objectives: to determine the prevalence of serum, genetic, and histological markers for gluten intolerance, and to analyze the response to gluten withdrawal from the diet in these patients. Methods: a number of patients with refractory anemia were prospectively and consecutively enrolled. A protocol to measure serum (TGt-2), genetic (HLA-DQ2/DQ8), and histological markers for celiac disease was applied. All followed a gluten-free diet for a median 3.6 years. Sustained remission of anemia during follow-up was interpreted as positive response. Results: ninety-eight patients (84% females) with a mean age of 54 years were studied. Anti-TGt2 antibodies were positive in 5% of cases. A total of 67 cases (68%) were haplotype HLA-DQ2 or -DQ8 (+). We found villous atrophy (Marsh III) in 13% of patients, and an inflammatory pattern (Marsh I or II) in 13%. All remaining 72 patients (74%) had no histological duodenal changes. Age, anemia duration, number of transfusions, number of parenteral iron doses, and time on a gluten-free diet were all compared according to the presence or absence of villous atrophy and HLADQ2/ 8 positivity, and no significant differences were found for any of the analyzed variables. Response was positive in 92% of subjects. Conclusions: celiac disease with villous atrophy is rarely a cause of refractory anemia. Gluten intolerance with no histological lesions is seen in almost 75% of patients, and therefore plays a relevant role in its development(AU)

[Refractory celiac disease]. / Enfermedad celíaca refractaria.

The main cause of lack of response to a gluten-free diet is continued, usually inadvertent, gluten intake. Diagnosis of refractory celiac disease is established on the basis of exclusion of other disorders, persistence of malabsorption and villous atrophy. Refractory celiac disease affects a heterogeneous group of patients, usually adults and, fortunately, is infrequent (<5% of the population). Detection of alterations in the intraepithelial lymphocyte population is essential for diagnosis. Some alterations in these lymphocytes, such as the absence of T cell surface receptor expression (CD3 and CD), indicate an aggressive form of the disease with the potential for malignant transformation (type II refractory celiac disease). Treatment is based on adequate nutritional support and on the use of corticosteroids and/or immunosuppressive agents (mainly azathioprine and infliximab). Because of the high risk of progression to intestinal T cell lymphoma, patients diagnosed with type 2 refractory disease require different -generally more aggressive- therapeutic strategies. At present, no treatment has been demonstrated to be effective in the long term, but two options that should be considered in type II disease are immunotherapy with anti-CD52 or similar agents, and autologous bone marrow transplantation. Trials with antibodies that block epithelial secretion of interleukin-15, a key molecule in the pathogenesis of the disease, are promising.