Dietary Supplement Use in Patients With Celiac Disease in the United States.

BACKGROUND: There has been increasing interest in the use of complementary and alternative medicine (CAM) in the general population. Little is known about CAM use in patients with celiac disease (CD). GOALS: We aimed to determine the demographics and clinical characteristics of patients with biopsy-proven CD who use dietary supplements to treat their symptoms. STUDY: CD patients completed a questionnaire on demographics, types of dietary supplement use, attitudes toward CAM, and 3 validated scales: CD-related Quality Of Life (CD-QOL), the CD Symptoms Index (CSI), and the CD Adherence Test (CDAT). RESULTS: Of 423 patients, 100 (23.6%) used dietary supplements to treat CD symptoms. The most frequently used supplement was probiotics (n=59). Supplement users had a higher CD-QOL score (75.06 vs. 71.43, P=0.04) but had more symptoms based on CSI (35.64 vs. 32.05, P=0.0032). On multivariable analysis, adjusting for age, sex, education, symptom improvement following a gluten-free diet, and where the survey was completed, patients presenting with classic symptoms (OR, 2.56; 95% CI, 1.01-6.44) or nonclassic symptoms (OR, 2.75; 95% CI, 1.04-7.24) were significantly more likely to use supplements than those with asymptomatic/screen-detected CD. CONCLUSIONS: Patients with biopsy-proven CD who have symptoms at diagnosis tend to use dietary supplements more than those that are screen detected. Those using supplements report persistent symptoms, but a higher quality of life. The contribution of the gluten-free diet and supplement use to quality of life in the symptomatic CD patient needs to be determined.

Methods to quantitate videocapsule endoscopy images in celiac disease.

In this work, bioengineering methods that can be used to quantitatively analyze videocapsule endoscopy images that have been acquired from celiac patients versus controls are described. For videocapsule endoscopic analysis, each patient swallows a capsule which contains an imaging device and light source. In celiac and control patients, images are acquired and analyzed at the level of the small intestine. The data used for videocapsule analysis consisted of high resolution images of dimension 576 × 576 pixels, acquired twice per second. The goal of the quantitative analysis is to detect abnormality in celiac patient images as compared with controls. Several types of abnormality can exist at the level of the small intestine in celiac patients. In untreated patients, and often even after treatment with a gluten-free diet, there can be villous atrophy, as well as presence of fissures and a mottled appearance. To detect and discern these abnormalities, several methods of statistical and structural feature extraction and selection are described. It was found that there is a significantly greater variation in image texture and average brightness level in celiac patients as compared with controls (p < 0.05). Celiac patients have a longer dominant period as compared with controls, averaging 6.4 ± 2.6 seconds versus 4.7 ± 1.6 seconds in controls (p = 0.001). This suggests that overall motility is slower in the celiac patients. Furthermore, the mean number of villous protrusions per image was found to be 402.2 ± 15.0 in celiac patients versus 420.8 ± 24.0 in control patients (p < 0.001). The average protrusion width was 14.66 ± 1.04 pixels in celiacs versus 13.91 ± 1.47 pixels in controls (p = 0.01). The mean protrusion height was 3.10 ± 0.26 grayscale levels for celiacs versus 2.70 ± 0.43 grayscale levels for controls (p < 0.001). Thus celiac patients tended to have fewer protrusions, and these were more varied in shape, tending to be blunted, as compared with controls, which more often had fine, uniform protrusions. A variety of computerized methods are now available to quantitate videocapsule images for comparison of celiac versus control patients. Since these methods are based on computer algorithms, they can be automated and there is no variation in the results due to observer bias. These methods readily lend themselves to automation, so that it may be possible to map the entire small intestine for presence of abnormality in real-time. It is also possible to develop an automated, quantitative clinical score which can be displayed with real-time update during the procedure. This would be useful to determine progress in celiac patients on a gluten-free diet, and to better understand the properties of the healing process in these patients.

Use of basis images for detection and classification of celiac disease.

Celiac disease commonly occurs in approximately 1% of populations, but it can be difficult to diagnose. The standard method to diagnose celiac disease includes analysis of endoscopy images of the small intestinal mucosa to detect presence of villous atrophy, which can be subtle. We have devised a means to improve the image-based detection of villous atrophy and other abnormality in videocapsule endoscopy by means of incorporating basis images. Basis images were extracted from a series of 200 consecutive image frames acquired over 100 seconds at the level of the duodenal bulb in 13 celiac patients and in 13 controls. They were converted from color to 256 grayscale levels (gsl; 0 = black, 255 = white). Eight basis images were used for analysis. A histogram was constructed for each basis image, and the mean and standard deviation of the histogram values were tabulated. The significance of the difference in histogram mean level for celiacs versus controls was determined. Then the histogram mean was plotted versus the standard deviation, separately for all eight basis images, and also averaged for all bases combined. The mean histogram level for celiacs was 127.59+6.05 gsl versus 129.25+5.53 gsl for controls (p< 0.05). Thus celiac basis images tended to be darker and also more variable as compared with controls. For nonlinear classification, using the average of combined basis images, the sensitivity was 84.6% while the specificity was 92.3%. Using the single most important basis image for nonlinear classification, the sensitivity was 84.6% while the specificity was 76.9%. Construction of basis images can be useful to condense videocapsule image series into salient information, for detection of differences in grayscale level mean and variation in celiac versus control image series, and for classification of celiac versus control videoclips with nonlinear discriminant functions.

Characteristics of patients who avoid wheat and/or gluten in the absence of Celiac disease.

BACKGROUND: Gastrointestinal symptoms that respond to the removal of wheat and/or gluten are becoming more common. Patients who avoid wheat and/or gluten (PWAWG) are a heterogeneous group and predominantly self-diagnosed prior to presenting for clinical evaluation. SPECIFIC AIM: We characterized PWAWGs seen at a tertiary care referral center and compared them to patients with celiac disease (CD) and subjects in the National Health and Nutrition examination survey (NHANES). METHODS: This was a cross-sectional study evaluating patients seen by four gastroenterologists at a CD referral center. Baseline characteristics, laboratory values, and medical comorbidities were compared to CD patients who presented at the same center and subjects enrolled in NHANES. RESULTS: Eighty-four PWAWGs were identified and compared to 585 CD patients and 2,686 NHANES patients. Thirty-two alternative diagnoses were made in 25 (30%) PWAWGs, including small intestinal bacterial overgrowth and fructose/lactose intolerance. When compared to patients with CD, PWAWGs had similar body mass index (BMI, 23.1 vs. 23.5, p = 0.54) and mean hemoglobin value (13.4 vs. 13.3, p = 0.6). When compared to male and female patients in NHANES, BMI, folate, and mean hemoglobin values were lower in PWAWGs. Both male and female PWAWGs had a lower prevalence of hypertension. CONCLUSION: While there are similarities between CD and PWAWGs that could possibly be due to shared HLA haplotypes or an effect of the gluten-free diet, alternative diagnoses are common in these patients. PWAWGs have a similar cardiovascular profile as CD patients in terms of lower BMI and lower prevalence of hypertension.

Interest in medical therapy for celiac disease.

OBJECTIVES: A gluten-free diet is the treatment for celiac disease, but pharmaceutical agents are being developed. The level of interest amongst patients in using a medication to treat celiac disease is unknown. This study examined the level of interest amongst patients in medication to treat celiac disease. METHODS: A questionnaire was distributed to celiac disease patients and data were collected on demographics, presentation, and interest in medication. Three validated celiac disease-specific instruments were incorporated: Celiac Disease Associated Quality of Life, the Celiac Symptom Index, and the Celiac Dietary Adherence Test. RESULTS: Responses were received from 365 individuals with biopsy-proven celiac disease. Respondents were 78% (n = 276) female, 48% (n = 170) over 50 years of age, and experienced a classical (diarrhea predominant) presentation in 44% (n = 154). Of the 339 individuals answering the question regarding use of a medication to treat celiac disease, 66% were interested. Interest was greatest in older individuals (71% >50 years of age versus 60% <50 years of age, p = 0.0415), men (78% men versus 62% women, p = 0.0083), frequent restaurant customers (76% versus 58%, p = 0.0006), those dissatisfied with their weight (73% versus 51%, p = 0.0003) and those concerned with the cost of a gluten-free diet (77% versus 64%, p = 0.0176). Length of time since diagnosis, education, presentation, and symptoms with gluten exposure did not demonstrate any effect. Interest in medication was associated with a worse quality of life (CD-QOL 69.4 versus 80.1, p < 0.0001). CONCLUSIONS: Most individuals with celiac disease are interested in using a medication. Interest was highest among men, older individuals, frequent restaurant customers, individuals dissatisfied with their weight or concerned with the cost of a gluten-free diet, and those with a worse quality of life.

Prevalence of gluten-free diet adherence among individuals without celiac disease in the USA: results from the Continuous National Health and Nutrition Examination Survey 2009-2010.

OBJECTIVES: Clinical inference suggests the prevalence of non-celiac gluten sensitivity is substantially higher than that of celiac disease in the USA. Unfortunately, there are currently no data supporting these claims. The authors analyzed nationally representative data to estimate the prevalence of adherence to a gluten-free diet among participants without celiac disease and also to characterize the demographics and general health status of these participants. STUDY DESIGN AND SETTING: The Continuous National Health and Nutrition Examination Survey (NHANES) 2009-2010 enrolled 7762 individuals representing the civilian, non-institutionalized, US population free of celiac disease. Participants responded to interviewer administered questionnaires regarding current adherence to a gluten-free diet. Prevalence estimates were computed using SAS survey procedures. RESULTS: There were 49 individuals who reported current adherence to a gluten-free diet reflecting a weighted prevalence of 0.548% (95% CI 0.206-0.889). The prevalence of a gluten-free diet was higher in females (0.58%) than males (0.37%), although this was not statistically significant (p = 0.34). Participants reporting a gluten-free diet were older (46.6 vs. 40.5 years, p = 0.005), had higher high-density lipoprotein, lower iron and lower body mass index. CONCLUSIONS: The estimated national prevalence of non-celiac gluten sensitivity is 0.548%, approximately half that of celiac disease. Future studies are merited in order to better understand the population burden of non-celiac gluten sensitivity.

Use of shape-from-shading to estimate three-dimensional architecture in the small intestinal lumen of celiac and control patients.

BACKGROUND: As measured from videocapsule endoscopy images, the small intestinal mucosa of untreated celiac patients has significantly greater and more varied texture compared to normal patients. Three-dimensional modeling using shape-from-shading principles may further increase classification accuracy. METHODS: A sequence of 200 consecutive videocapsule images acquired at a 2s(-1) frame rate and 576×576 pixel dimension, were obtained at four locations in the small intestinal lumen of ten patients with biopsy-proven celiac disease and ten control patients. Each two-dimensional image was converted to a three-dimensional architectural approximation by considering the 256 grayscale level to be linearly representative of image depth. From the resulting three-dimensional architecture, distinct luminal protrusions, representative of the macro-architecture, were automatically identified by computer algorithm. The range and number of protrusions per image, and their width and height, were determined for celiacs versus controls and tabulated as mean±SD. RESULTS: The mean number of villous protrusions per image was 402.2±15.0 in celiacs versus 420.8±24.0 in controls (p<0.001). The average protrusion width was 14.7 pixels in celiacs versus 13.9 pixels in controls (p=0.01). The mean protrusion height was 3.10±2.34 grayscale levels for celiacs versus 2.70±0.43 grayscale levels for controls (p<0.001). Thus celiac patients had significantly fewer protrusions on the luminal surface of the small intestine as compared with controls, and these protrusions had greater dimensions, suggesting they are indicative of a mosaic (cobblestone) macro-architectural pattern which is common in celiacs. CONCLUSIONS: Shape-from-shading modeling is useful to explore luminal macro-architecture and to detect significant differences in luminal morphology in celiac versus normal patients, which can increase the usefulness of videocapsule studies.

Implementation of a polling protocol for predicting celiac disease in videocapsule analysis.

AIM: To investigate the presence of small intestinal villous atrophy in celiac disease patients from quantitative analysis of videocapsule image sequences. METHODS: Nine celiac patient data with biopsy-proven villous atrophy and seven control patient data lacking villous atrophy were used for analysis. Celiacs had biopsy-proven disease with scores of Marsh II-IIIC except in the case of one hemophiliac patient. At four small intestinal levels (duodenal bulb, distal duodenum, jejunum, and ileum), video clips of length 200 frames (100 s) were analyzed. Twenty-four measurements were used for image characterization. These measurements were determined by quantitatively processing the videocapsule images via techniques for texture analysis, motility estimation, volumetric reconstruction using shape-from-shading principles, and image transformation. Each automated measurement method, or automaton, was polled as to whether or not villous atrophy was present in the small intestine, indicating celiac disease. Each automaton's vote was determined based upon an optimized parameter threshold level, with the threshold levels being determined from prior data. A prediction of villous atrophy was made if it received the majority of votes (≥ 13), while no prediction was made for tie votes (12-12). Thus each set of images was classified as being from either a celiac disease patient or from a control patient. RESULTS: Separated by intestinal level, the overall sensitivity of automata polling for predicting villous atrophy and hence celiac disease was 83.9%, while the specificity was 92.9%, and the overall accuracy of automata-based polling was 88.1%. The method of image transformation yielded the highest sensitivity at 93.8%, while the method of texture analysis using subbands had the highest specificity at 76.0%. Similar results of prediction were observed at all four small intestinal locations, but there were more tie votes at location 4 (ileum). Incorrect prediction which reduced sensitivity occurred for two celiac patients with Marsh type II pattern, which is characterized by crypt hyperplasia, but normal villous architecture. Pooled from all levels, there was a mean of 14.31 ± 3.28 automaton votes for celiac vs 9.67 ± 3.31 automaton votes for control when celiac patient data was analyzed (P < 0.001). Pooled from all levels, there was a mean of 9.71 ± 2.8128 automaton votes for celiac vs 14.32 ± 2.7931 automaton votes for control when control patient data was analyzed (P < 0.001). CONCLUSION: Automata-based polling may be useful to indicate presence of mucosal atrophy, indicative of celiac disease, across the entire small bowel, though this must be confirmed in a larger patient set. Since the method is quantitative and automated, it can potentially eliminate observer bias and enable the detection of subtle abnormality in patients lacking a clear diagnosis. Our paradigm was found to be more efficacious at proximal small intestinal locations, which may suggest a greater presence and severity of villous atrophy at proximal as compared with distal locations.

Is dietitian use associated with celiac disease outcomes?

A gluten-free diet (GFD) is the treatment for celiac disease (CD), but due to its complexity, dietitian referral is uniformly recommended. We surveyed patients with CD to determine if dietitian use is associated with quality of life, symptom severity, or GFD adherence. The survey utilized three validated CD-specific instruments: the CD quality of life (CD-QOL), CD symptom index (CSI) and CD adherence test (CDAT). Four hundred and thirteen patients with biopsy-proven CD were eligible for inclusion. The majority (77%) were female and mean BMI was 24.1. Over three-quarters of patients (326, 79%) had seen a dietitian, however, 161 (39%) had seen a dietitian only once. Age, sex, and education level were not associated with dietitian use; nor was BMI (24.6 vs. 24.0, p = 0.45). On multivariate analysis, adjusting for age gender, education, duration of disease, and body mass index, dietitian use was not associated with CD-QOL, CSI, or CDAT scores. Our survey did not show an association between dietitian use and symptom severity, adherence, or quality of life. Delay in diagnosis was associated with poorer outcomes. This is a preliminary study with several limitations, and further prospective analysis is needed to evaluate the benefits and cost-effectiveness of dietitian-referral in the care of celiac disease patients.

Villous atrophy and negative celiac serology: a diagnostic and therapeutic dilemma.

OBJECTIVES: Patients with villous atrophy (VA) and negative celiac disease (CD) serologies pose a diagnostic and therapeutic dilemma. When a definitive etiology for VA is not determined, patients are characterized as having unclassified sprue (US), the optimal management of which is unknown. METHODS: We studied adult patients with VA on biopsy and negative celiac serologies, evaluated at our tertiary referral center over a 10-year period. Testing for HLA DQ2/8 alleles, antienterocyte antibodies, giardia stool antigen, bacterial overgrowth, total serum immunoglobulins, and HIV was noted. Treatment, response, and repeat-biopsy findings were recorded. RESULTS: The most common diagnoses of the 72 patients were seronegative CD, medication-related villous atrophy, and US. Of those with US, the majority reported symptomatic improvement with immunosuppressive therapy. Some patients initially labeled as unclassified were found to have VA associated with olmesartan use. CONCLUSIONS: The role of medications in the development of VA and the optimal dose and length of immunosuppression for patients with US should be investigated further.

Prevalence of migraine in patients with celiac disease and inflammatory bowel disease.

OBJECTIVE: To assess the prevalence of headache in clinic and support group patients with celiac disease and inflammatory bowel disease (IBD) compared with a sample of healthy controls. BACKGROUND: European studies have demonstrated increased prevalence of headache of patients with celiac disease compared with controls. METHODS: Subjects took a self-administered survey containing clinical, demographic, and dietary data, as well as questions about headache type and frequency. The ID-Migraine screening tool and the Headache Impact Test (HIT-6) were also used. RESULTS: Five hundred and two subjects who met exclusion criteria were analyzed - 188 with celiac disease, 111 with IBD, 25 with gluten sensitivity (GS), and 178 controls (C). Chronic headaches were reported by 30% of celiac disease, 56% of GS, 23% of IBD, and 14% of control subjects (P<.0001). On multivariate logistic regression, celiac disease (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.78-8.10), GS (OR 9.53, 95%CI 3.24-28.09), and IBD (OR 2.66, 95%CI 1.08-6.54) subjects all had significantly higher prevalence of migraine headaches compared with controls. Female sex (P=.01), depression, and anxiety (P=.0059) were independent predictors of migraine headaches, whereas age >65 was protective (P=.0345). Seventy-two percent of celiac disease subjects graded their migraine as severe in impact, compared with 30% of IBD, 60% of GS, and 50% of C subjects (P=.0919). There was no correlation between years on gluten-free diet and migraine severity. CONCLUSIONS: Migraine was more prevalent in celiac disease and IBD subjects than in controls. Future studies should include screening migraine patients for celiac disease and assessing the effects of gluten-free diet on migraines in celiac disease.

Small bowel imaging in celiac disease.

Celiac disease is a common inflammatory disease of the small intestine triggered by gluten in genetically susceptible individuals. Diagnosis is made by serologic testing and upper endoscopy with small bowel biopsy in most individuals. Celiac patients may present with abdominal pain or nonspecific gastrointestinal complaints that result in radiologic imaging before diagnosis of celiac disease. Wireless video capsule endoscopy, device-assisted enteroscopy, and enterography allow careful examination of the entire small bowel and targeted sampling of suspicious lesions. This review focuses on the role of device-assisted enteroscopy and radiologic imaging, in particular enterography, in celiac disease.

Video capsule endoscopy in celiac disease.

Video capsule endoscopy (VCE) provides a safe, non-invasive way to visualize the small intestine and is helpful in celiac disease patients in select situations. VCE can be performed in patients who are unable or unwilling to undergo conventional endoscopy, those with positive celiac serology with normal duodenal biopsies, and also in those who develop alarm symptoms. VCE has limitations including subjective interpretation. Techniques are being developed to standardize assessment of VCE images in patients with known or suspected celiac disease. Pilot studies using computer-based quantification methods have shown promise in examining the 3-dimensional mucosal structure and motility.

Copper levels in patients with celiac neuropathy.

OBJECTIVE: Neurological complications of celiac disease (CD) include neuropathy, myeloneuropathy, and cerebellar degeneration. The cause of neuropathy in patients with CD is not known. Prior publications describe copper deficiency in CD patients with myeloneuropathy and neuropathy and posit that hypocupremia is the cause of these neurological conditions. However, based on our clinical experience, we hypothesized that CD patients with polyneuropathy are not deficient in copper. METHODS: Patients who met diagnostic criteria for CD and peripheral neuropathy were included. We reviewed the patient's records, including assessment of serum copper level and other clinical parameters. RESULTS: Eighteen patients met inclusion criteria. Sixteen patients (89%) had normal copper levels, 2 had mild hypercupremia, and none had low copper levels. Of the 18 patients, 4 (22%) had large fiber neuropathy and 14 (78%) had a small fiber neuropathy. CONCLUSIONS: No patient in this study showed hypocupremia. We are unable to demonstrate a relationship between our CD patients with Peripheral Neuropathy and copper deficiency.

Sex and racial disparities in duodenal biopsy to evaluate for celiac disease.

BACKGROUND: Celiac disease (CD) is common but underdiagnosed in the United States. Serological screening studies indicate that, although CD occurs at the same frequency in both sexes, women are diagnosed more frequently than men (2:1). CD is less frequently diagnosed among black patients, though the seroprevalence in this group is not known. OBJECTIVE: To measure the rates of duodenal biopsy during EGD for symptoms consistent with CD. DESIGN: Retrospective cohort study. SETTING: Clinical Outcomes Research Initiative National Endoscopy Database, spanning the years 2004 through 2009. PATIENTS: Adults undergoing EGD for the indication of diarrhea, anemia, iron deficiency, or weight loss, in which the endoscopic appearance of the upper GI tract was normal. MAIN OUTCOME MEASUREMENT: Performance of duodenal biopsy. RESULTS: Of 13,091 individuals (58% female patients, 9% black patients) who met the inclusion criteria, duodenal biopsy was performed in 43%, 45% of female patients and 39% of male patients (P < .0001). Black patients underwent duodenal biopsy in 28% of EGDs performed compared with 44% for white patients (P < .0001). On multivariate analysis, male sex (odds ratio [OR] 0.81; 95% CI, 0.75-0.88), older age (OR for 70 years and older compared with 20-49 years, 0.51; 95% CI, 0.46-0.57), and black patients (OR 0.55; 95% CI, 0.48-0.64) were associated with decreased odds of duodenal biopsy. LIMITATIONS: Lack of histopathologic correlation with CD prevalence. CONCLUSIONS: In this multiregional endoscopy database spanning the period from 2004 through 2009, rates of duodenal biopsy increased modestly over time, but overall remained low in patients with possible clinical indications for biopsy. Nonperformance of duodenal biopsy during endoscopy may be contributing to the underdiagnosis of CD in the United States.

Quantitative estimates of motility from videocapsule endoscopy are useful to discern celiac patients from controls.

BACKGROUND: Prior work has shown that videocapsule endoscopy image features are a useful tool for quantitatively distinguishing the intestinal mucosal surface of untreated celiac patients from that of controls. The use of dynamic estimates of wall motility may further help to improve classification. METHODS: Videocapsule endoscopy clips (200 frames each, 2 frames/s, 576 × 576 pixels/frame) were acquired at five small intestinal locations in 11 untreated celiac patients (celiacs) and ten controls. Color images were converted to grayscale and analyzed frame-by-frame. Variations in the position and width of the center of the small intestinal lumen were quantitatively estimated. The darkest grayscale pixels were used as an estimate of the lumen center. Over 200 frames, the standard deviation of the lumen center xy position and the mean and standard deviation in lumen center width were used as dynamic estimates of wall motility. These parameters were plotted in three-dimensional space, and the best discriminant function was used to classify celiacs versus controls at each of the following five locations: (1) duodenal bulb, (2) distal duodenum, (3) jejunum, (4) ileum, and (5) distal ileum. RESULTS: The overall sensitivity for the classification of celiacs versus controls at all five locations was 98.2 %, while the specificity was 96.0 %. From location 1 to 5, there was a tendency for the lumen center width to diminish in terms of frame-to-frame variability by 7.6 % in celiacs (r (2) = 0.4) and 9.7 % in controls (r (2) = 0.7). CONCLUSIONS: In addition to examining the mucosal surface, videocapsule endoscopy can assess small bowel intestinal motility and aid in distinguishing celiac patients from controls.

Transformation of videocapsule images to detect small bowel mucosal differences in celiac versus control patients.

BACKGROUND: Videocapsule endoscopy can be useful to detect small intestinal pathology in celiac disease patients. However, presence of extraneous features including air bubbles and opaque fluids can complicate the analysis. A technique for quantitative analysis of videocapsule images is presented that is robust to presence of extraneous features. METHOD: Videocapsule clips were acquired from five small intestinal locations in 12 celiacs with villous atrophy and 11 control patients. Clips were 200 frames in length, their resolution was 576 × 576 pixels and 256 grayscale levels, with 2/s frame rate. The dominant period (DP), defined as the tallest peak in the ensemble average power spectrum, was computed over each clip without removal of extraneous features. Ensemble average basis images were constructed, and measurements were made of their frame-to-frame variation in brightness and texture. RESULTS: From pooled basis images, celiac images had greater texture than controls and exhibited more brightness variation (p<0.05 in mean and p<0.01 in standard deviation). In celiacs, correlation existed between greater textural alterations versus longer DP (r²=0.47), and between greater brightness variation and longer DP (r²=0.33). There was no significant correlation between quantitative features and DP in controls (r²<0.25). CONCLUSIONS: Using this new method, celiac videoclips were quantitatively distinguishable from control videoclips without manual or computer-assisted detection, masking, and removal of extraneous image features. Furthermore, in celiac but not control basis images, larger textural and brightness alterations were correlated to longer DP. Greater textural and brightness alterations, and thus longer periodicities, are likely related to presence of villous atrophy.

Variability in small bowel histopathology reporting between different pathology practice settings: impact on the diagnosis of coeliac disease.

BACKGROUND AND AIMS: Coeliac disease (CD) diagnosis requires the detection of characteristic histological alterations of small bowel mucosa, which are prone to interobserver variability. This study evaluated the agreement in biopsy interpretation between different pathology practice types. METHODS: Biopsies from community hospitals (n=46), university hospitals (n=18) and commercial laboratories (n=38) were blindly assessed by a pathologist at our institution for differences in histopathology reporting and agreement in diagnosis of CD and degree of villous atrophy (VA) by κ analysis. RESULTS: Agreement for primary diagnosis was very good between this institution and university hospitals (κ=0.888), but moderate compared with community hospitals (κ=0.465) or commercial laboratories (κ=0.419). Diagnosis differed in 26 (25%) cases, leading to a 20% increase in CD diagnosis after review. Among those diagnosed with CD by both institutions (n=49), agreement in degree of VA was fair (κ=0.292), with moderate agreement between the authors and commercial laboratories (κ=0.500) and fair with university hospitals (κ=0.290) or community hospitals (κ=0.211). The degree of VA was upgraded in 27% and downgraded in 2%. Within different Marsh score categories, agreement was poor (κ<0.0316) for scores 1 and 2, both missed at other centres, and fair or moderate for scores 3a and 3b. Information regarding degree of VA and intraepithelial lymphocytosis was lacking in 26% and 86% of reports and non-quantifiable descriptors, eg, 'blunting' or 'marked atrophy' were prevalent. CONCLUSIONS: CD-related histological changes are underdiagnosed in community-based hospitals and commercial pathology laboratories. Because incorrect biopsy interpretation can cause underdiagnosis of CD, greater CD awareness and uniformity in small bowel biopsy reporting is required among pathologists.

Increased sedation requirements during endoscopy in patients with celiac disease.

BACKGROUND: Celiac disease (CD) is associated with increased rates of neuropsychiatric disease and irritable bowel syndrome, and patients may exhibit visceral hypersensitivity. AIM: The purpose of this study was to determine whether patients with CD have increased sedation requirements during endoscopic procedures. METHODS: In this retrospective cohort study, we identified CD patients undergoing either a colonoscopy or esophagogastroduodenoscopy (EGD), but not a dual procedure. CD patients were matched with control patients according to age, gender and endoscopist. For sedation requirements we defined "high" as falling outside of the 75th percentile of the entire cohort. RESULTS: In the colonoscopy analysis we identified 113 CD patients and 278 controls. In the CD group, 29 individuals (26%) required high amounts of both opioids and midazolam, as compared to 46 (17%) controls (P = 0.05). Differences were similar when considering only opioids (P = 0.06) and midazolam (P = 0.06). In the EGD analysis we identified 314 CD patients and 314 controls who met the inclusion criteria. Among the CD patients, 70 (22%) required high amounts of both opioids and midazolam compared to 51 (16%) controls (P = 0.05). Differences were similar when considering only opioids (P = 0.06) and midazolam (P = 0.04). CONCLUSIONS: Patients with CD require higher doses of sedation during upper and lower endoscopy compared to age and gender-matched controls. Putative explanations, such as visceral hypersensitivity, chronic opioid/anxiolytic use, or underlying neuropsychiatric illness, should be evaluated prospectively.