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Awareness of Physicians on Celiac Disease and the Effect of Education
Abstract
Celiac disease is a genetic in origin, systemic autoimmune disease that can be occur at any stage of life. The onset of the disease is triggered by dietary intake of wheat, barley and rye containing gluten prolamins. The prevalence of the disease is around 1% and this rate is expected to increase as awareness increases. Due to celiac disease mimicking the symptoms of other diseases and being known as a rare disease, the diagnosis rate is low, and patients are often diagnosed late. In this study, we evaluated the awareness rates of physicians and investigated the effect of celiac training on awareness rate. Our research is a pre-test and post-test compatibility study prepared in cross-sectional style. Family physicians who participated in the meeting on May 9, 2019, Celiac Day were included in our study. The pre-test was distributed to physicians just before the meeting. A training module on celiac disease was presented to the participants and a final test was performed afterwards. When the pre-test and post-test were matched, the questionnaires of 88 physicians were analyzed. Kappa coefficient was calculated for nominal scale information and Kendall’s tau-b correlation coefficient for ordinal scale questions were calculated. A binary logistic regression model was created according to the situation of encountering celiac patients in the study environment. In the whole study, type-I error value was taken as 5% and p<0.05 value was accepted as statistically significant. The mean age of the participants was 30.91±6.69 years. The mean number of patients suspected of celiac disease was 3.13 in the participants who stated that they had seen 767 patients in a month. The mean for patients diagnosed with celiac disease was 1.56 in the last year. When celiac-related conditions are evaluated, the states with the highest awareness are chronic diarrhea (100%), weight loss (98.9%), and anemia (96.6%), respectively, while the least common conditions were genetic syndromes (14.8-20.5%) and gynecological problems and infertility (39.8-42%). In the last test after the training, it was found that almost all the awareness was around 90%. The change between pre-test and post-test was significant for most statements (p<0.001). When the comparisons between the pre-test and post-test on the self-sufficient visual scale provided to the physicians were made, the difference was observed as significant in both (Wilcoxon test, p <0.001). Chronic diarrhea, weight loss, anemia, and dyspepsia were the most well-known conditions related to celiac disease in our study, while gynecological problems and genetic syndromes were the least known. It was determined that typical celiac disease is known more, and atypical celiac disease is less known. At the end of the training, it was observed that the awareness rate increased in all findings. The results of the study support that reminding of celiac disease with in-service training given both in residency training and in primary care can increase the diagnosis rates.
Autoimmune disorders may cause systemic disease in which multiple organs are affected or may also be localized as single-organ involvement. Various ancillary immunological tests used in cases where systemic involvement is observed, and differential diagnosis becomes difficult or non-specific symptoms are observed. For this purpose, investigation of antinuclear antibodies (ANA) and antibodies against extractable nuclear antigens (ENA) in patient serums using various methods is a guide for clinicians. In this study, we aimed to evaluate the effectiveness of ANA and ENA antibody tests by examining the test results, the patients’ demographic data, and the clinics that ordered the tests. In the study, a retrospective review of the results of 37,791 ANA tests studied on serum samples sent to the medical microbiology laboratory of our hospital from various clinics between January 2018 and December 2022 is presented. ANA tests were resulted semi-quantitatively by evaluating the slides prepared using diluted serum samples at a ratio of 1:100 and HEp-2 cells and monkey liver tissue under a fluorescent microscope with the indirect immunofluorescence (IIF) antibody method. Of the patients who requested ANA test, 11,604 (30.7%) were male and 26,187 (69.3%) were female. The mean ages were 43.46 (0-94) and 46.94 (0-96), respectively. Of the samples tested, 18.8% (7,107/37,791) were evaluated as ANA positive. The ANA positivity rate was significantly higher in women (24.8%) than in men (19.7%) (p<0.001). ANA positive samples were re-tested using the anti-ENA immunoblot method. Of the 7,107 ANA-positive patients, 3,809 (53.6%) were found to be anti-ENA positive for at least one specific antibody, while 3,298 (46.4%) were negative. In the anti-ENA profile, antibodies against 11 different antigen types were screened and the most frequently detected antibody was anti-SS-A (22.7%), and this was followed by anti-centromere (12.8%), anti-RNP (10.2%), and anti-dsDNA (9.7%) antibodies. Immunoblot-based anti-ENA tests provide specific information for the diagnosis of autoimmune diseases. In our study, the fact that anti-ENA tests were negative in a significant part of ANA positive patients indicates the inadequacy of the immunoblot test panel and reveals the need for immunoblot tests with wider antibody diversity or any alternative methods.
Celiac disease (CD) is a systemic autoimmune disease due to a dysregulated mucosal immune response to gluten and related prolamines in genetically predisposed individuals. It is a common disorder affecting ~1% of the general population, its incidence is steadily increasing. Changes in the clinical presentation have become evident since the 80s with the recognition of extra-intestinal symptoms like short stature, iron deficiency anemia, altered bone metabolism, elevation of liver enzymes, neurological problems. Recent studies have shown that the overall prevalence of extra-intestinal manifestations is similar between pediatric and adult population; however, the prevalence of specific manifestations and rate of improvement differ in the two age groups. For instance, clinical response in children occurs much faster than in adults. Moreover, an early diagnosis is decisive for a better prognosis. The pathogenesis of extra-intestinal manifestations has not been fully elucidated yet. Two main mechanisms have been advanced: the first related to the malabsorption consequent to mucosal damage, the latter associated with a sustained autoimmune response. Importantly, since extra-intestinal manifestations dominate the clinical presentation of over half of patients, a careful case-finding strategy, together with a more liberal use of serological tools, is crucial to improve the detection rate of CD.
Celiac disease is a multiform, challenging condition characterized by extremely variable features. Our goal was to define clinical, serological and histopathological findings in a large cohort of celiacs diagnosed in a single referral center.
From January 1998 to December 2012, 770 patients (599 females, median age 36 years, range 18-78 years) were diagnosed as celiacs at St.Orsola-Malpighi Hospital (Bologna, Italy). The clinical phenotypes were classified as: 1) classical (malabsorption syndrome); 2) non-classical (extraintestinal and/or gastrointestinal symptoms other than diarrhea); 3) subclinical. Serology, duodenal histology, comorbidities, response to gluten-free diet and complications were evaluated.
Disease onset was symptomatic in 610 patients (79%), while 160 celiacs showed a subclinical phenotype. In the symptomatic group the non-classical prevailed over the classical phenotype (66% vs 34%). Diarrhea was found in 27%, while other gastrointestinal manifestations were bloating (20%), aphthous stomatitis (18%), alternating bowel habit (15%), constipation (13%) and gastroesophageal reflux disease (12%). Extraintestinal manifestations included osteopenia/osteoporosis (52%), anemia (34%), cryptogenic hypertransaminasemia (29%) and recurrent miscarriages (12%). Positivity for IgA tissue transglutaminase antibodies was detected in 97%. Villous atrophy was found in 87%, while 13% had minor lesions consistent with potential celiac disease. A large proportion of patients showed autoimmune disorders, i.e. autoimmune thyroiditis (26.3%), dermatitis herpetiformis (4%) and diabetes mellitus type 1 (3%). Complicated celiac disease was very rare.
Our study demonstrates that the clinical profile of celiac disease changed over time with an increasing rate of non-classical and subclinical phenotypes.
Celiac disease (CeD) is an immune-mediated enteropathy triggered by ingestion of gluten in genetically susceptible individuals. CeD is a global disease and estimated to affect approximately one percent of the global population. With advent of simple serological tests for the diagnosis, the number of individuals diagnosed with CeD is increasing exponentially. It was initially thought that gluten hypersensitivity in CeD is limited to small intestine only and all other features are secondary to malabsorption, but it is now recognized that the hypersensitivity to gluten is not limited to small intestine alone and may affect other organs such as skin, brain, and bones independent of intestinal involvement. CeD is now considered a multi-system disorder and their clinical presentation may be with gastrointestinal symptoms, called “classical CeD” or more often with non-gastrointestinal symptoms called “non-classical CeD”. These patients may present with short stature, anemia, liver dysfunction (asymptomatic increase in transaminases, chronic liver disease, autoimmune hepatitis), cutaneous manifestations (dermatitis herpetiformis, oral ulcers), reproductive diseases (infertility, recurrent abortions), neurological manifestations (ataxia, peripheral neuropathy), and metabolic disorders (osteopenia/osteoporosis). What determines these variable phenotypes remain unclear but likely is a result of genetic as well as environmental factors. Many of these patients with non-classical CeD are likely to report to specialists other than gastroenterologists such as hematologists, endocrinologists, rheumatologists or gynecologists. Unfortunately, the awareness about non-classical presentations of CeD amongst health care professionals remains low. There is an urgent need to increase awareness among health care professionals about varied manifestations of CeD in order to decrease the burden of undiagnosed CeD.
BACKGROUND
An increased risk of reproductive failures in women with celiac disease (CD) has been shown by several studies but a comprehensive evaluation of this risk is lacking. Furthermore, the pathogenic mechanisms responsible for obstetric complications occurring in CD have not been unraveled.METHODS
To better define the risk of CD in patients with reproductive disorders as well as the risk in known CD patients of developing obstetric complications, we performed an extensive literature search of Medline and Embase databases. Odds ratio (OR) and relative risk (RR) with 95% confidence intervals (95% CI) were used in order to combine data from case-control and cohort studies, respectively. All data were analyzed using Review Manager software. In addition, we summarized and discussed the current hypotheses of pathogenic mechanisms potentially responsible for obstetric complications occurring in CD.RESULTSPatients with unexplained infertility, recurrent miscarriage or intrauterine growth restriction (IUGR) were found to have a significantly higher risk of CD than the general population. The OR for CD was 5.06 (95% CI 2.13-11.35) in patients with unexplained infertility, 5.82 (95% CI 2.30-14.74) in women experiencing recurrent miscarriage and 8.73 (95% CI 3.23-23.58) in patients with IUGR. We did not observe an increased risk of CD in women delivering small-for-gestational age or preterm babies. Furthermore, we found that in celiac patients, the risk of miscarriage, IUGR, low birthweight (LBW) and preterm delivery is significantly higher with an RR of 1.39 (95% CI 1.15-1.67), 1.54 (95% CI 1.22-1.95), 1.75 (95% CI 1.23-2.49) and 1.37 (95% CI 1.19-1.57), respectively. In addition, we observed that the risk for IUGR, LBW and preterm delivery was significantly higher in untreated patients than in treated patients. No increased risk of recurrent miscarriage, unexplained stillbirth or pre-eclampsia was found in celiac patients. In vitro studies have provided two main pathogenic models of placental damage at the feto-maternal interface. On the embryonic side of the placenta, a direct binding of anti-transglutaminase (-TG) antibodies to trophoblast cells and, thus, invasiveness reduction via an apoptotic damage, has been proposed. Anti-TG antibodies may also be detrimental to endometrial angiogenesis as shown in vitro in human endometrial endothelial cells (cultures and in vivo in a murine model). The angiogenesis inhibition seems to be the final effect of anti-TG antibody-mediated cytoskeletal damage in endometrial endothelial cells.CONCLUSIONS
Physicians should investigate women with unexplained infertility, recurrent miscarriage or IUGR for undiagnosed CD. Women with CD show an increased risk of miscarriage, IUGR, LBW and preterm delivery. However, the risk is significantly reduced by a gluten-free diet. These patients should therefore be made aware of the potential negative effects of active CD also in terms of reproductive performances, and of the importance of a strict diet to ameliorate their health condition and reproductive health. Different mechanisms seem to be involved in determining placental tissue damage in CD patients.
This guideline presents recommendations for the diagnosis and management of patients with celiac disease. Celiac disease is an immune-based reaction to dietary gluten (storage protein for wheat, barley, and rye) that primarily affects the small intestine in those with a genetic predisposition and resolves with exclusion of gluten from the diet. There has been a substantial increase in the prevalence of celiac disease over the last 50 years and an increase in the rate of diagnosis in the last 10 years. Celiac disease can present with many symptoms, including typical gastrointestinal symptoms (e.g., diarrhea, steatorrhea, weight loss, bloating, flatulence, abdominal pain) and also non-gastrointestinal abnormalities (e.g., abnormal liver function tests, iron deficiency anemia, bone disease, skin disorders, and many other protean manifestations). Indeed, many individuals with celiac disease may have no symptoms at all. Celiac disease is usually detected by serologic testing of celiac-specific antibodies. The diagnosis is confirmed by duodenal mucosal biopsies. Both serology and biopsy should be performed on a gluten-containing diet. The treatment for celiac disease is primarily a gluten-free diet (GFD), which requires significant patient education, motivation, and follow-up. Non-responsive celiac disease occurs frequently, particularly in those diagnosed in adulthood. Persistent or recurring symptoms should lead to a review of the patient's original diagnosis to exclude alternative diagnoses, a review of the GFD to ensure there is no obvious gluten contamination, and serologic testing to confirm adherence with the GFD. In addition, evaluation for disorders associated with celiac disease that could cause persistent symptoms, such as microscopic colitis, pancreatic exocrine dysfunction, and complications of celiac disease, such as enteropathy-associated lymphoma or refractory celiac disease, should be entertained. Newer therapeutic modalities are being studied in clinical trials, but are not yet approved for use in practice. Given the incomplete response of many patients to a GFD-free diet as well as the difficulty of adherence to the GFD over the long term, development of new effective therapies for symptom control and reversal of inflammation and organ damage are needed. The prevalence of celiac disease is increasing worldwide and many patients with celiac disease remain undiagnosed, highlighting the need for improved strategies in the future for the optimal detection of patients.Am J Gastroenterol advance online publication, 23 April 2013; doi:10.1038/ajg.2013.79.
It is suggested that patients with constipation should be screened for celiac disease. Similarly, it is recommended to investigate these patients for hypothyroidism and hypercalcemia. However, no evidence for these recommendations is available so far. We therefore set out to determine the prevalence of celiac disease, hypothyroidism, and hypercalcemia in children with constipation.
Prospective cohort study of 370 consecutive patients who met the Rome III criteria for constipation. These patients were referred by a general practitioner to a pediatrician because of failure of laxative treatment.
Seven of these patients had biopsy-proven celiac disease. This is significantly higher (p < 0.001) than the 1:198 prevalence of celiac disease in the Netherlands. Two patients had auto-immune thyroiditis. No patient had hypercalcemia.
We conclude that celiac disease is significantly overrepresented in patients with constipation who are referred by a general practitioner to a pediatrician because of failure of laxative treatment. All such patients should, therefore, be screened for celiac disease.
Celiac disease (CD) is a common illness, affecting 0.5-1% of the population. Its classic presentation consists of gastrointestinal symptoms, however, many extra-intestinal symptoms and some associated diseases have been studied. Pediatricians should know the typical and atypical presentations of CD and how to diagnosis and treat its complications. The aim of this study was describe what pediatricians in Brazil know about CD.
A descriptive, cross-sectional study with pediatricians who participated in the Nestlé Pediatrics Course, in the city of Natal, Brazil, in 2008. They were asked to complete a self-applicable questionnaire covering aspects concerning the prevalence, diagnosis, and treatment of CD and the conditions associated with this disease.
A total of 632 pediatricians completed the questionnaire. The majority of respondents (82.9%) were female. All the geographical regions of Brazil were represented. More than 65% of respondents had undergone specialist training in pediatrics, and 40% of respondents had worked as pediatricians for more than 25 years. Only 22% replied that celiac disease may be asymptomatic, 57% stated that antigliadin antibody measurement represents the best screening tool for the disease, and two-thirds replied that bowel biopsy would be the most indicated method. The pathologies and conditions associated with celiac disease were identified by fewer than 50% of respondents. Exclusion of gluten from the patient's diet was mentioned as the treatment for celiac disease by 86.4% of the pediatricians.
We conclude that pediatricians have superficial information about CD. The need for relevant information on celiac disease is fundamental and is recognized by the pediatricians themselves.
There is an increased prevalence of osteoporosis among patients with celiac disease. However, the relative prevalence of celiac disease among osteoporotic and nonosteoporotic populations is not known, and the benefit of screening the osteoporotic population for celiac disease remains controversial.
We evaluated 840 individuals, 266 with and 574 without osteoporosis, from the Washington University Bone Clinic by serologic screening for celiac disease. Individuals with positive serologic test results for antitissue transglutaminase or antiendomysial antibody were offered endoscopic intestinal biopsy to confirm the diagnosis of celiac disease. Individuals with biopsy-proven celiac disease were treated with a gluten-free diet and followed up for improvement in bone mineral density.
Twelve (4.5%) of 266 patients with osteoporosis and 6 (1.0%) of 574 patients without osteoporosis tested positive by serologic screening for celiac disease. All but 2 serologically positive individuals underwent in-testinalbiopsy. Nine osteoporotic patients and 1 nonosteoporotic patient had positive biopsy results. The prevalence of biopsy-proven celiac disease was 3.4% among the osteoporotic population and 0.2% among the nonosteoporotic population. All biopsy-positive individuals tested positive by antitissue transglutaminase and antiendomysial antibody. The antitissue transglutaminase levels correlated with the severity of osteoporosis as measured by T score, demonstrating that the more severe the celiac disease the more severe the resulting osteoporosis. Treatment of the patients with celiac disease with a gluten-free diet resulted in marked improvement in T scores.
The prevalence of celiac disease among osteoporotic individuals (3.4%) is much higher than that among nonosteoporotic individuals (0.2%). The prevalence of celiac disease in osteoporosis is high enough to justify a recommendation for serologic screening of all patients with osteoporosis for celiac disease.
Celiac disease is a common systemic disorder that can have multiple hematologic manifestations. Patients with celiac disease may present to hematologists for evaluation of various hematologic problems prior to receiving a diagnosis of celiac disease. Anemia secondary to malabsorption of iron, folic acid, and/or vitamin B12 is a common complication of celiac disease and many patients have anemia at the time of diagnosis. Celiac disease may also be associated with thrombocytosis, thrombocytopenia, leukopenia, venous thromboembolism, hyposplenism, and IgA deficiency. Patients with celiac disease are at increased risk of being diagnosed with lymphoma, especially of the T-cell type. The risk is highest for enteropathy-type T-cell lymphoma (ETL) and B-cell lymphoma of the gut, but extraintestinal lymphomas can also be seen. ETL is an aggressive disease with poor prognosis, but strict adherence to a gluten-free diet may prevent its occurrence.
A close correlation between celiac disease (CD) and oral lesions has been reported. The aim of this case-control study was to assess prevalence of enamel hypoplasia, recurrent aphthous stomatitis (RAS), dermatitis herpetiformis and atrophic glossitis in an Italian cohort of patients with CD.
Fifty patients with CD and fifty healthy subjects (age range: 3-25 years), matched for age, gender and geographical area, were evaluated by a single trained examiner. Diagnosis of oral diseases was based on typical medical history and clinical features. Histopathological analysis was performed when needed. Adequate univariate statistical analysis was performed.
Enamel hypoplasia was observed in 26% cases vs 16% in controls (p > 0.2; OR = 1.8446; 95% CI = 0.6886: 4.9414). Frequency of RAS in the CD group was significantly higher (36% vs 12%; p = 0.0091; OR = 4.125; 95% CI = 1.4725: 11.552) in CD group than that in controls (36% vs 12%). Four cases of atrophic glossitis and 1 of dermatitis herpetiformis were found in CD patients vs 1 and none, respectively, among controls.
The prevalence of enamel hypoplasia was not higher in the study population than in the control group. RAS was significantly more frequent in patients with CD.
Introduction:
The objective of this study was to evaluate the relation between age at diagnosis and compliance to gluten free diet (GFD) on growth in children with celiac disease and the factors that influenced compliance to GFD.
Population and methods:
Celiac disease (CD) patients with villous atrophy followed in our hospital between January 2015 and January 2017, were included. They were classified according to diagnosis age and GFD compliance. Patients' anthropometric characteristics at diagnosis and follow-up were compared.
Results:
There were 73 patients with 10.4 ± 4.5 years of average age, 35 (47.9%) patients had a short stature at diagnosis, the ages of patients who had short stature (7.8 ± 4.2 years) were higher than those who did not (5.1 ± 4.3 years) (p= 0.005). At diagnosis, 33 (45.2%) patients were aged ≤6 years, 40 (54.8%) were aged >6 years. The height and weight z-scores of patients who were diagnosed at >6 years of age were significantly lower than those who were diagnosed ≤6 years of age both at diagnosis (p= 0.01 and 0.04) and at last control (p= 0.001 and 0.001), respectively. Forty-five (61.6%) patients were fully compliant with GFD. In comparison of anthropometric data in terms of GFD compliance, the increase in BMI and weight z-score in the fully compliant group was found to be significantly higher when compared with the other group.
Conclusions:
Delay in CD diagnosis negatively affected both the height and weight and other growth parameters. GFD compliance positively affected the patients' all growth parameters, especially weight and BMI z-score.
Guidelines recommend routine screening of liver function tests (LFTs) in patients diagnosed with celiac disease (CD). However, little is known about the prevalence of liver disorders in CD outside of Europe. Our aims were to estimate the prevalence of LFT abnormalities in CD and to evaluate the effect of a gluten-free diet (GFD) on LFTs.
Adult patients with biopsy-proven CD were identified from a prospectively maintained database and matched with healthy controls. LFT levels for women and men were defined as abnormal based on the Third National Health and Nutrition Examination Survey (NHANES III) criteria. Data on demographics, coexisting liver diseases, and laboratory work-ups including aspartate transaminase (AST) and alanine transaminase (ALT) values at the time of diagnosis and on a GFD were recorded. Subsequently, data from this cohort were compared with data from 7,789 individuals participating in the National Health and Nutrition Examination Survey, 2009-2010. Univariate logistic regression, Wilcoxon signed-ranks, Student's t-test, χ(2), and Fischer's exact test were used for statistical analysis.
In 463 CD patients with ALT or AST levels at the time of CD diagnosis, 40.6% had elevated LFTs compared with 24.2% of treated CD patients (P<0.001) and 16.6% of matched controls (P<0.001). Similarly, 36.7% of CD patients on the NHANES database had abnormal ALT values compared with 19.3% of non-celiac patients (P=0.03). Approximately, 78.6% of CD patients with elevated LFTs at diagnosis normalized LFTs on a GFD after a mean duration of 1.5±1.5 years.
Forty percent of individuals will have elevated LFTs at CD diagnosis; however, the majority will normalize with standard CD therapy. LFTs should be checked in all patients with CD and coexisting liver disorder should be considered in patients whose LFTs have not improved within a year on a GFD.Am J Gastroenterol advance online publication, 7 July 2015; doi:10.1038/ajg.2015.192.
Within the past 20 years the spectrum of complications of coeliac disease (CD) has been considerably extended. Besides the classic complications, autoimmune diseases and osteopenia, numerous forms of CD non-responsive to a gluten-free diet have been recently identified. Among the non-responsive CD, the majority of patients presents as long term responders. However a small subset of CD patients becomes refractory to a gluten-free diet with persistent malabsorption and intestinal villous atrophy. Whereas refractory coeliac disease type I (RCDI) is hardly distinguishable from active CD, the type II (RCDII) has a severe clinical presentation and a very poor prognosis. Enteropathy Associated T cell Lymphoma (EATL) is even more aggressive with a five year survival of 20%. Classic adriamycin-based chemotherapy is poorly efficient in the lymphomatous complications of CD and current therapeutic strategies focus on more intensive regimen with autologous or allogenic stem cell transplantation. Notable pathogenic advances let us to test targeted therapy both in low (RCDII) and high grade lymphomatous (EATL) complications associated with CD.
Copyright © 2015 Elsevier Ltd. All rights reserved.
Mild liver abnormalities are common in patients with celiac disease and usually resolve with a gluten-free diet. We investigated the occurrence of celiac disease in patients with severe liver failure.
Four patients with untreated celiac disease and severe liver disease are described. Further, the occurrence of celiac disease was studied in 185 adults with previous liver transplantation using serum immunoglobulin A endomysial and tissue transglutaminase antibodies in screening.
Of the 4 patients with severe liver disease and celiac disease, 1 had congenital liver fibrosis, 1 had massive hepatic steatosis, and 2 had progressive hepatitis without apparent origin. Three were even remitted for consideration of liver transplantation. Hepatic dysfunction reversed in all cases when a gluten-free diet was adopted. In the transplantation group, 8 patients (4.3%) had celiac disease. Six cases were detected before the operation: 3 had primary biliary cirrhosis, 1 had autoimmune hepatitis, 1 had primary sclerosing cholangitis, and 1 had congenital liver fibrosis. Only 1 patient had maintained a long-term strict gluten-free diet. Screening found 2 cases of celiac disease, 1 with autoimmune hepatitis and 1 with secondary sclerosing cholangitis.
The possible presence of celiac disease should be investigated in patients with severe liver disease. Dietary treatment may prevent progression to hepatic failure, even in cases in which liver transplantation is considered.
The average prevalence of coeliac disease among children with diabetes mellitus in 26 reports was 4.5% (0.97-16.4%). Malabsorption, unstable diabetes, and growth failure, indicate that coeliac disease may be present. Even those who are apparently asymptomatic may have subtle complaints indicative of coeliac disease if a careful history is taken. Ill health may only be recognised in retrospect following the benefits conferred by a gluten free diet. For these reasons it is recommended that a screening programme should be instituted to detect coeliac disease in these children. Parents and where possible children themselves, should be fully involved at all stages of the screening, diagnostic, and treatment process.
Celiac disease (CD) may be associated with other immunologic disorders in adults and children. Previous studies linking CD and autoimmune thyroid disease in children have included very few patients with limited biochemical and immunologic screening tests. The aim of this multicenter study was to establish the prevalence of autoimmune thyroid involvement in a large series of pediatric patients with CD.
Five hundred seventy-three consecutive pediatric patients were enrolled from clinics in Torino, Bologna, Foggia, Rome (two clinics), Naples, and Bari. Three hundred forty-three patients with CD were studied, 230 girls and 113 boys (median age, 8.5 years). Two hundred fifty-six of the patients with CD (median age, 9 years) had been following a gluten-free diet for 3 months to 16 years; 87 patients were untreated (median age, 6.2 years). The diagnosis of CD was made using the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) criteria. A control group of 230 subjects (median age, 8.3 years) was enrolled. Serum free triiodothyronine, free thyroxine, and thyroid-stimulating hormone (TSH), antithyroperoxidase, antithyroglobulin, anti-TSH receptor antibodies, and thyroid echographic pattern were considered.
Autoimmune thyroid disease was found in 90 of 343 (26.2%) patients with CD (62 on a gluten-free diet) and in 20 (10%) of the control subjects (P = 0.001). Fifty-four (15.7%) patients with CD and autoimmune markers had normal thyroid function (euthyroidism) as did 12 (6.0%) of the control subjects; hypothyroidism was observed in 28 (8.1%) patients with CD and in 7 (3.5%) of the control subjects. Hyperthyroidism was diagnosed in four patients with CD and in none of the control subjects with autoimmune markers. An abnormal echographic pattern was seen in 37 patients with CD (16.8%) and only in 1 (1.6%) of the control subjects (P = 0.002).
The high frequency of autoimmune thyroid disease found among patients with CD, even those on a gluten-free diet, may justify a thyroid status assessment at diagnosis and at follow-up evaluation of children with CD.
The aim of this study was to investigate the presence and distribution of developmental enamel defects and caries in children with celiac disease (CD) and compare the results obtained with those of a control group of children without CD. A total of 64 subjects (mean age 8.2 years) selected from patients diagnosed and treated for CD were studied. Sixty-four age/ sex-matched healthy children were enrolled as a control group. Permanent dentition enamel defects were recorded according to Aine's classification. The caries experience of the children was recorded according to the criteria of the World Health Organization (WHO). The prevalence of enamel defect in CD subjects was found to be significantly higher (42.2%) than in healthy subjects (9.4%) (p < 0.001). Grade I type enamel defects were most commonly diagnosed in both groups (20.3% and 6.3%, respectively). The number of caries-free subjects in the control group was higher (38%) than in the CD group (17%). This study clearly showed that children with CD were at an increased risk of dental enamel defects compared with healthy subjects. Enamel defects were associated with an increased caries incidence.
Çölyak Hastalığında Aile Hekimleri İçin Tanı, Tedavi̇ ve İzlem Rehberi. T.C. Sağlık Bakanlığı Yayın No: 1111; Ankara
- T C Bakanlığı
- Türkiye Ankara
T.C. Sağlık Bakanlığı, Ankara, Türkiye. Çölyak
Hastalığında Aile Hekimleri İçin Tanı, Tedavi̇ ve İzlem
Rehberi. T.C. Sağlık Bakanlığı Yayın No: 1111; Ankara,
2019.
Available
at:
https://hsgm.saglik.gov.tr/depo/Yayinlarimiz/Rehberle
r/Collyak_Hastaliginda_Aile_Hekimleri_Icin_Tani_tedav
i_Izlem_rehberi_07_02_2019.pdf [Accessed February
26, 2023].