Non celiac gluten sensitivity and diagnostic challenges

Non-celiac gluten sensitivity [NCGS], also referred to as non-celiac wheat sensitivity [NCWS], is a clinical syndrome characterized by both intestinal and extra-intestinal symptoms responsive to the withdrawal of gluten-containing food from the diet. The aim of this review is to summarize recent advances in research and provide a brief overview of the history of the condition for the benefit of professionals working in gastroenterology. Academic databases such as PubMed and Google Scholar were searched using key words such as 'non-celiac gluten sensitivity', 'gluten related disorders', and the studies outlined in reference page were selected and analysed.Most of the analysed studiers agree that NCGS would need to be diagnosed only after exclusion of celiac disease and wheat allergy, and that a reliable serological marker is not available presently. The mechanisms causing symptoms in NCGS after gluten ingestion are largely unknown, but recent advances have begun to offer novel insights. The estimated prevalence of NCGS, at present, varies between 0.6 and 6%. There is an overlap between irritable bowel syndrome and NCGS with regard to the similarity of gastrointestinal symptoms. The histologic characteristics of NCGS are still under investigation, ranging from normal histology to slight increase in the number of T lymphocytes in the superficial epithelium of villi. Positive response to gluten free diet for a limited period [e.g., 6 weeks], followed by the reappearance of symptoms after gluten challenge appears, at this moment, to be the best approach for confirming diagnosis. The Salerno expert criteria may help to diagnose NCGS accurately in particular for research purposes but it has limited applicability in clinical practice

Post pancreatitis/cholecystectomy gluten intolerance

This case report describes the journey of a patient who suffered from life-limiting gastrointestinal symptoms after an acute bout of pancreatitis following ERCP for cholelithiasis bile following a ductal stone, and subsequent cholecystectomy. She was diagnosed and treated for IBS with medication without significant improvement. On implementation of a simple gluten and lactose exclusion diet she recovered to her premorbid state, and trials of gluten challenge triggered flares of symptoms. This case report will go on to discuss current evidence for use of gluten and lactose exclusion diets in some gluten sensitive patients misdiagnosed with IBS

What is the best algorithm for investigation of acute lower gastrointestinal haemorrhage?

An 81-year-old male presented with multiple episode of severe PR bleeding over 2 days. CTA done prior to catheter angiography that enabled successful intervention. This case emphasises the importance of CTA prior to catheter angiography in acute LGIB

unusual diagnosis for persistent diarrhoea and vomiting

Identifying the etiology of chronic diarrhoea might be challenging in some patients, and before a diagnosis is made these patients may spend a sulostantial length of time with unresolved symptoms leading to uncertainty and anxiety that is severely impairing their life quality. A 45-year-old female was referred by her general practitioner with a 5-year history of increasingly frequent episodes of cyclical diarrhoea, vomiting, abdominal pain and intermittent palpitations. Contrast CT Abdomen/Pelvis revealed a 36x33x46 mm mass in the aorto caval region of her retro-peritoneum, just above the bifurcation. On the basis of her symptoms, CT findings and an elevated plasma metanephrine level of 2314pmol/L [normal range 80 - 510pmol/L], it was at this point a likely diagnosis of a Phaeochromocytoma was made. The retroperitoneal mass was successfully resected, and the histology confirmed a phaeochromocytoma. Her symptoms rapidly improved and she made a good recovery. This unusual case highlights some of the dilemmas that arise when investigating patients with chronic and recurrent diarrhoea and vomiting

Economic burden made celiac disease an expensive and challenging condition for Iranian patients

Aim: The aim of this study was to estimate the economic burden of celiac disease [CD] in Iran

Background: The assessment of burden of CD has become an important primary or secondary outcome measure in clinical and epidemiologic studies

Methods: Information regarding medical costs and gluten free diet [GFD] costs were gathered using questionnaire and checklists offered to the selected patients with CD. The data included the direct medical cost [including Doctor Visit, hospitalization, clinical test examinations, endoscopies, etc.], GFD cost and loss productivity cost [as the indirect cost] for CD patient were estimated. The factors used for cost estimation included frequency of health resource utilization and gluten free diet basket. Purchasing Power Parity Dollar [PPP dollars] was used in order to make inter-country comparisons

Results: Total of 213 celiac patients entered to this study. The mean [standard deviation] of total cost per patient per year was 3377 [1853] PPP dollars. This total cost including direct medical cost, GFD costs and loss productivity cost per patients per year. Also the mean and standard deviation of medical cost and GFD cost were 195 [128] PPP dollars and 932 [734] PPP dollars respectively. The total costs of CD were significantly higher for male. Also GFD cost and total cost were higher for unmarried patients

Conclusion: In conclusion, our estimation of CD economic burden is indicating that CD patients face substantial expense that might not be affordable for a good number of these patients. The estimated economic burden may put these patients at high risk for dietary neglect resulting in increasing the risk of long term complications

Protein-protein interaction network of celiac disease

Aim: The aim of this study is to investigate the Protein-Protein Interaction Network of Celiac Disease

Background: Celiac disease [CD] is an autoimmune disease with susceptibility of individuals to gluten of wheat, rye andbarley. Understanding the molecular mechanisms and involved pathway may lead to the development of drug targetdiscovery. The protein interaction network is one of the supportive fields to discover the pathogenesis biomarkers for celiacdisease

Material and Methods: In the present study, we collected the articles that focused on the proteomic data in celiac disease.According to the gene expression investigations of these articles, 31 candidate proteins were selected for this study. Thenetworks of related differentially expressed protein were explored using Cytoscape 3.3 and the PPI analysis methods suchas MCODE and ClueGO

Results: According to the network analysis Ubiquitin C, Heat shock protein 90kDa alpha [cytosolic and Grp94]; class A, Band 1 member, Heat shock 70kDa protein, and protein 5 [glucose-regulated protein, 78kDa], T-complex, Chaperon incontaining TCP1; subunit 7 [beta] and subunit 4 [delta] and subunit 2 [beta], have been introduced as hub-bottlnecksproteins. HSP90AA1, MKKS, EZR, HSPA14, APOB and CAD have been determined as seed proteins

Conclusion: Chaperons have a bold presentation in curtail area in network therefore these key proteins beside the other hubbottlneckproteins may be a suitable candidates biomarker panel for diagnosis, prognosis and treatment processes in celiac disease

Post gastroenteritis gluten intolerance

The spectrum of gluten related disorder might be much broader than currently believed. It is unknown why non-coeliac gluten sensitivity affects individuals at different ages. It is quite possible that triggering factors like infection might play an essential role in manifestation of this disorder. Similar to secondary lactose intolerance, gluten intolerance might be a common occurrence behind persistent symptoms after gastroenteritis. Presenting symptoms may depend on etiological factors and the affected portion of gastrointestinal [GI] anatomy. Therefore symptoms might be related to the upper GI tract like functional dyspepsia, or the lower GI tract like diarrhoea and constipation or a combination of both as in our patients. This case highlights that intolerance to gluten may develop in people who experience gastroenteritis and there is potential of at least partial recovery from this condition with elimination of lactose and gluten. Clinical recovery with a concomitant gluten and lactose [mainly milk] free diet over a period of time might be an effective strategy in treating these patients

Elemental diets role in treatment of high ileostomy output and other gastrointestinal disorders

Elemental diet [ED] has been used widely in the treatment of gastrointestinal disorders, especially with the management of Crohn's disease. This modality of diets provides all essential nutrients, and contains protein in the form of free amino acids that are theoretically easily absorbed. High output ileostomies are a rare but important complications of stoma formation following bowel surgery. Treatments could be challenging and include anti-diarrhoeals, octreotide and proton pump inhibitors. There is very little research regarding the use of elemental diets in the treatment of patients with post-operative high ileostomy outputs. Adequate management of high output ileostomies might prevent significant morbidity. In this case report, we describe a patient who underwent a subtotal colectomy for ulcerative colitis complicated by refractory high ileostomy output despite maximal standard medical therapy for years. The ileostomy output was dramatically reduced following the introduction of an elemental diet. This case suggests a possible role for the introduction of an elemental diet in the management of high output ileostomies. Besides presenting this case with high output ileostomy, we reviewed the role of ED in other gastrointestinal disorders

Non-coeliac gluten sensitivity and reproductive disorders

An association between coeliac disease and fertility disorders is well recognised in the current literature, but the information related to non-coeliac gluten sensitivity [NCGS] and infertility is lacking. This case highlights a possible role of treating NCGS in the reversal of infertility

H.pylori associated with iron deficiency anemia even in celiac disease patients; strongly evidence based but weakly reflected in practice

Inflammation can lead to malabsorption of important micronutrients such as iron. Malabsorption and nutritional deficiency can be caused by a variety of pathological and environmental factors causing a range of other symptoms commonly caused by both H. pylori infection and coeliac disease [CD]. National guidelines suggest the routine taking of duodenal biopsies to exclude CD when investigating patients for iron deficiency anemia [IDA]. Studies suggest that in absence of positive antibodies, IDA is rarely caused by CD. Recent British Society of Gastroenterology guidelines discourage the routine duodenal biopsies in low risk cases but despite this guidance, taking duodenal biopsies for IDA is a common practice. Many studies have reported that H. pylori infection is associated with IDA even in patients with CD. In countries with low H. pylori prevalence we still detect more H. pylori than CD standing behind IDA. Despite the strong association between IDA and H. pylori, taking biopsies to diagnose H. pylori infection is not usually a routine part of the diagnostic workup to identify the etiology of IDA. In this review we will discuss the impact of H. pylori in IDA and highlight the possible gaps in identifying the IDA etiology

Mucosal histopathology in celiac disease: a rebuttal of Oberhuber's sub-division of Marsh III

Individuals with particular genetic backgrounds develop immune responses to wheat proteins and become [gluten- sensitized]. Mucosal pathology arises through activated mucosal T lymphocytes, resulting in a graded, adverse reaction between particular genes and wheat proteins. Given these varied influences, the Marsh Classification broadly itemises those stages through which a normal mucosa [Marsh 0] evolves in becoming [flat] [Marsh I, II, III]. Recently, Oberhuber and colleagues suggested that Marsh III lesions required subdividing into a, b, c categories. We critically examined these subdivisions by means of correlative light and scanning electron microscopy [SEM]. Our results demonstrate that Oberhuber's classification is untenable. In our view deriving from our observations, the artificial subdivisions proposed by those authors actually reflect misinterpretations of the true architectural contours of flat mucosae. Although these workers refer to [villous projections], SEM demonstrates that no such structures are present on flat - or immediately recovering - mucosae. Our data revealed on the surfaces of flat [Marsh III] mucosae, large open [basins], surrounded by raised collars - the latter, when viewed in histological section, being easily misconstrued as [villi]. It seems that with subsequent upward growth, these collars coalesce into low ridges, thence becoming broader and higher convolutions. It is noticeable that there are more open spaces on the surfaces of flat mucosae than was appreciated hitherto. We conclude that Oberhuber's revisions of Marsh III into three subcategories [a, b, c], are misinterpretations of the histological appearances of flattened mucosae. Therefore, histopathologists when classifying celiac mucosae, since they add nothing either of diagnostic, nor prognostic, value should resist these subcategories

Type 1 diabetes mellitus and gluten induced disorders

Over the last five decades the association between coeliac disease and other autoimmune disorders such as autoimmune thyroid disease or diabetes mellitus type 1 has been well established through many studies and to this day is subject to on-going clinical and scientific investigation worldwide. While no link has been established between celiac disease and type-2 diabetes mellitus, coeliac disease is common in patients with type 1 diabetes. The improvement of symptoms in patients with both conditions through dietary intervention, in the form of a gluten free diet, has been widely described within the literature. Our objectives were to review and synthesise the current knowledge on the nutritional treatment for patients with both conditions