Celiac Dz - Peds

8/12/2019 Celiac Dz - Peds

1/12

Silent CD describes the situation of an individualwithout signs or symptoms of CD, but who has small

bowel biopsy evidence of CD; usually these patients

have an associated condition or a family history of

CD, and are identified on screening as having CD-

associated antibodies. Latent CD applies to individuals without signs or

symptoms of CD, but who have some risk for future

development of CD, such as expression of CD-

related antibodies or DQ2 or DQ8 permissive genes,

family history of CD, or having an associated condi-

tion. These individuals do not have small bowel

biopsy changes, but may have CD-associated anti-

bodies. Refractory CD describes an individual with defined

CD who continues to have signs or symptoms of

active CD despite pursuing a GFD. In this situation,

considerations include considered exposure to gluten,

enteropathy-associated T-cell lymphoma (EATL), or

possibly another condition such as allergy or inflam-

matory bowel disease.

Incidence and Prevalence

The prevalence in the United States and Europe is

roughly 313 cases per 1000 individuals (1:300 to

1:80).1There is a female predominance with a ratio of

roughly 2:1.2 These estimates indicate that there areapproximately 3 million people with CD in the United

States alone, and a roughly equal number in Europe, of

which 90% are undiagnosed (Table 181). Recent

screening studies suggest that in developing countries

in Africa, parts of Asia, and South America, the fre-

quency is similar to that of the U.S. and European

countries.3To date, there are very little data exploring

DEFINITIONS AND EPIDEMIOLOGYCeliac disease (CD) is a permanent sensitivity to gluten

in wheat and related proteins found in barley and rye,

occurring in genetically susceptible individuals, and

manifesting as an immune mediated enteropathy as

defined by characteristic changes seen on intestinal his-

tology.1A conservative definitionrequires the following:

typical signs or symptoms; presence of CD-associated antibodies; a small intestinal biopsy showing villous atrophy; resolution of clinical manifestations with a gluten-

free diet (GFD), including complete healing of the

intestinal mucosa; reduction or disappearance of the CD-associated

antibodies on a GFD.

In practice, it is questionable whether it is neces-

sary to meet all aspects of this definition. Controversy

continues about whether a small bowel biopsy is required

to diagnose CD. Because of numerous reports of CD-

associated seropositive individuals with no signs or

symptoms of CD, guidelines continue to require a

biopsy to confirm the diagnosis and need for

treatment.

Different terms have been applied to common

clinical situations:

Classic CDrefers to a presentation with typical clini-cal features such as diarrhea, abdominal pain, failure

to thrive, or abdominal distention. Atypical CDdescribes a non-traditional presentation,

primarily with extraintestinal manifestations, such as

arthritis or iron deficiency anemia. In older children

and adults, the atypical presentation may be more

common than the classic presentation.

Celiac DiseaseEdward Hoffenberg

CHAPTER18

Bishop_Ch18_265 276.indd 265Bishop_Ch18_265-276.indd 265 4/6/10 2:34/6/10 2:3


2/12

266 Section 3: Disorders of the Stomach and Intestine

the rates of CD in China, Japan, and Southeast Asian

countries, and these populations are thought to be at

lower genetic risk for CD. A number of conditions are

associated with an increased risk of CD in children and

adults (Table 182).

Genetic Considerations

Specific HLA types are permissive for development of

CD. HLA molecules bind peptide antigens and presentthem to CD4helper T cells. An estimated 95% of CD

patients express the HLA-DQ2 gene and the remain-

der express DQ8.5HLA II molecules are made up of

dimers, expressing one alpha and one beta chain. The

vast majority of CD patients express the HLA II sub-

type DQ2 coded by alleles DQA1*0501 and DQB*0201,

or DQ8 coded by alleles DRB*04-DQA1*03-

DQB1*0302. The DQ2 dimer contains specific pockets

that bind deamidated gluten peptides and present

them to CD4lymphocytes. Expressing two copies of

HLA-DQ2 (homozygous state) increases the risk for

developing CD, and an estimated 25% of CD patients

are DQ2 homozygous. The genes coding for HLA II

are located on chromosome 6p21, termed the CELIAC1locus.

However, other genetic factors are important,

and the absolute necessity of DQ2/DQ8 for develop-

ment of CD has been questioned, as apparent cases of

CD occur in individuals who do not express DQ2 or

DQ8.2,4The DQ2 gene is expressed by approximately

30% of Caucasians, but only 3% of these develop CD.

Having a first-degree relative with CD increases the

risk of CD to between 5% and 18%.4There is an esti-

mated 7086% concordance in monozygotic twins

with CD, but only 3040% with HLA-matched twins,

and less than 20% concordance in dizygotic twins and

first-degree relatives.6Expression of DQ2 or DQ8 onlyaccounts for approximately 3653% of the disease

risk. Therefore, other genetic and environmental fac-

tors are important.7,8 Gene linkage analysis and

genetic-associated studies, including genome-wide

association studies, have identified a number of other

loci of possible importance in CD5,9 (Tables 183

and 184).

Worldwide Disease Prevalence Based on

Screening Data

Argentina

Australia

Brazil

Egypt

Finland

India

Iran

Israel

Italy

Netherlands

Russia

Spain

Sweden

Tunisia

Turkey

United KingdomUnited States

1:167

1:251

1:66 to 1:119

1:187

1:99 to 1:67

1:310

1:166 to 1:104

1:157

1:106

1:198

1:133

1:118

1:77

1:157

1:115

1:1001:105

Table 181.

Conditions Associated with Increased Risk for CD

in Children and Adults1,4,11

Condition Prevalence of CD (%)

Type 1 diabetes

Down syndrome

Turner syndrome

Williams syndrome

IgA deficiency

Autoimmune thyroiditis

First-degree relatives with CD

Second-degree relatives

Dermatitis herpetiformis

Short stature/delayed puberty

Dental enamel defects

Adults specifically: Irritable bowel syndrome Persistent aphthous stomatitis Peripheral neuropathy Unexplained cerebellar ataxia Elevated transaminases Unexplained iron deficiency

anemia Decreased bone mineral density Infertility

816

315

48

10

28

8

518

3

80100

Table 182.

Genetic Linkage Studies5,9

Locus Gene Region Function

CELIAC1 6p21 HLA II coding region

CELIAC2 5q315q33 Cytokine gene cluster

CELIAC3 2q33 T-cell regulatory genes

CELIAC4 19p13.1 MYO9Bunconventional

myosin molecule

Table 183.



3/12

CHAPTER 18 Celiac Disease 267

Pathogenesis

The exact mechanism by which ingestion of gluten pro-

teins by genetically susceptible individuals leads to

immune-mediated intestinal injury remains unclear

(Figure 181). An inciting event such as a viral infec-

tion, plus additional genetic factors, may be important

to development of CD. Both innate and adaptive immu-

nity are thought to be involved.

Gluten proteins are found in wheat and related

grains, and can be divided into gliadin and glutenin

components. Hordeins in barley and secalins in rye are

equivalent proteins that promote the CD process. The

oat avedin protein is more distantly related to Triticeae

Gluten

Gut lumen Brush border

Deamidated

peptideAPC

T cell

TG2

Mucosal

epithelium

TG2

CD4 + T cell

CD4 TCR

HLA-DQ2or -DQ8

APC

Lamina propria

FIGURE 181 Cartoon highlighting steps involved in pathogenesis of CD.41 Gluten peptides survive digestion and

cross the mucosal epithelium, where deamidation by tissue transglutaminase (TG2) occurs. HLA-DQ2 or -DQ8 molecules

on antigen-presenting cells present these peptides in the intestinal lamina propria where they are recognized by specific

CD4T cells Adapted by permission from Ref.41(Macmillan Publishers Ltd).

Genetic Association Studies5,4345

Gene Region Function/Association

1q31 Contains RGS1, regulator of G protein signaling molecule. Involved in B-cell act ivation/proliferation; found

in intestinal intraepithelial lymphocytes

2q112q12 2 genes coding for receptor for IL-18 that stimulates T-cell synthesis of IFN-gamma

3p21 Large cluster of chemokine receptor genes CCR1, CCR2, CCR3, CCR5, CCRL2, and XCR1

3q253q26 Immediately 5of IL-12 gene. IL-12 induces Th1 IFN-gamma secretion

3q28 Associated with LPP gene of unclear significance

4q27 Strongest current association with CD outside HLA locus. Cluster of 8 associated single nucleotide

polymorphisms; 2 contain genes for IL2 and IL21, involved in T-cell activation. Associated with type 1

diabetes and rheumatoid arthritis

6q25 Contains TAGAP gene (T-cell activation GTPase-activating protein) expressed in act ivated T cel ls

12q24 Contains LNK and ATXN2strongly expressed in monocytes, dendritic cel ls, and small intest ine

Table 184.



4/12


glutens, and seems to be non-immunogenic for most

CD patients.10

Several properties of gluten may be important in

stimulating the immune response of CD:

Gliadin stimulation of IL-15 secretion through a non-

HLA-binding mechanism. Gliadin induction of zonulin expression in small

intestinal epithelium, with subsequent increase in

intestinal permeability, CD4T-cell antigen exposure,

and alteration in cell morphology. The high proline (15%) and glutamine (35%) content

confers important chemical properties to gluten. First,

gluten peptides resist human acid and peptic diges-

tion, and reach the intestinal mucosa in antigenic seg-

ments. Second, constitutively expressed tissue trans-

glutaminase (TTG) in the small intestine alters gliadin

peptides by deamidating specific glutamine residues

to the negatively charged glutamate. Individuals with

CD express antibodies to both TTG and deamidated

gliadin peptides; these antibodies are specific sero-logic markers for CD. Deamidated gliadin peptides

show enhanced binding to specific pockets in the DQ2

molecule, resulting in enhanced presentation to

CD4T cells by local antigen-presenting cells

(APCs).

Both activated APCs and CD4T cells secrete

increased amounts of inflammatory cytokines such as

IFN-gamma and IL-15, causing local recruitment of

fibroblasts and clonal expansion of cytotoxic intraepi-

thelial lymphocytes (IELs). The increased numbers of

IELs and the subsequent mucosal damage are the

classic changes seen on intestinal biopsy of CD

patients.

CLINICAL PRESENTATION

Well-recognized clinical presentations of pediatric CD

include: failure to thrive, chronic diarrhea, distended

abdomen, irritability, constipation, and growth or puber-

tal delay (Table 185).1,11 Extraintestinal manifestations

such as arthritis, iron deficiency anemia, dental enameldefects, and dermatitis herpetiformis (DH) are also com-

mon. Asymptomatic children may be identified on

screening because of increased risk due to having an

associated condition or a family history of CD or diabe-

tes (Table 182). Recently, a variety of presentations have

been imputed to be related to undiagnosed CD in adults

(Table 182). These include neuropsychiatric presenta-

tions such as ataxia and epilepsy, as well as infertility.

Because the signs and symptoms may be mild, vague,

and non-specific, delays in diagnosis are common.1113

Celiac crisis is a rare medical emergency charac-

terized by explosive, watery diarrhea and dehydration/

electrolyte imbalances, marked abdominal distension,

hypotension, and lethargy. It is typically seen in toddlers

and responds to corticosteroids within a few days.

Clinical Course/Progression of Disease

With institution of a GFD, symptoms often improve by

the second week, but may take months to completely

resolve. Normalization of the intestinal histology may

take 612 months. Lactose intolerance tends to resolve

within a few weeks. Treatment of nutritional deficien-

cies, such as iron deficiency, is generally not needed over

long term. Adults tend to improve more slowly.

For those with silent or latent CD, continued expo-

sure to gluten leads to eventual clinical manifestations in

Manifestations of CD1,11

Classic CD Extraintestinal Neuropsychiatric Symptoms

Failure to thrive* Dermatitis herpetiformis* Ataxia

Diarrhea* Dental enamel defects* Epilepsy/cerebral calcifications

Abdominal distension* Anemia* Migraines

Vomiting* Aphthous stomatitis* Depression

Abdominal pain* Arthritis/arthralgias Fatigue/malaise

Constipation* Abnormal liver function tests* Anxiety

Pubertal delay/short stature* Peripheral neuropathy

Osteoporosis/osteopenia*

Infertility

Recurrent fetal loss

*Strong evidence for association.Less strong.

Table 185.



5/12


at least some individuals.14Data from the adult literature

also show a mortality risk significantly above the stan-

dard mortality rate (SMR) by a factor of two- to three-

fold for patients not adhering to a GFD, not responding

to the GFD, or with lengthy delay in diagnosis.15There is

reasonable evidence that early compliance with a GFD

reduces the risk of mortality to close to baseline.16

Malignancy

The two- to three-fold increase in all-cause mortality in

CD adult patients, as compared to controls, is mostly

due to gastrointestinal malignancies such as EATL, non-

Hodgkin lymphoma (NHL), and small bowel adenocar-

cinoma. CD is associated with an increased relative risk

2.16.6 times above baseline for NHL and a 30-fold

increased risk for small bowel adenocarcinoma.16

Dermatitis Herpetiformis

DH is the most common skin lesion associated with CD,

occurring in up to 24% of adult patients with CD, but is

rare in children. Classic DH is a chronic, pruritic, papu-

lar/vesicular rash symmetrically located on the extensor

surfaces of the elbows, knees, buttocks, back, and sacrum,

and occasionally is seen on the face, neck, and trunk.

Biopsy of skin lesions shows microabscesses with neu-

trophils and eosinophils in the dermal papillae. Immu-

nofluorescence of adjacent skin shows IgA deposits in

the papillary dermis directed toward an unknown anti-

gen, but theorized to possibly be epidermal transglu-

taminase. Markers of CD are often elevated in DH, with

positive TTG IgA, endomyseal antibody assay (EMA),

and anti-gliadin antibody assays (AGA). The vast major-ity of DH patients will have villous flattening or increased

IELs, even in the absence of overt gastrointestinal symp-

toms. Most, 8590%, are HLA B8 positive, and there is a

strong association with HLA DW3, and DRW3. A glu-

ten-containing diet is necessary to manifest the lesions of

DH, and symptoms often resolve with GFD. Dapsone is

often used as a suppressive medication.1,17,18

Skeletal ManifestationsThere is strong evidence supporting the increased risk

for osteopenia and osteoporosis in untreated CD. Bone

mineral density, area, and content may be reduced but

assessment should adjust for growth and pubertal delay.

In children, bone density normalizes within 12 years of

treatment with GFD.19

Association with OtherAutoimmune Diseases

The most commonly seen concurrent autoimmune dis-

eases are type 1 diabetes and Hashimoto thyroiditis.

Less common are associations with juvenile arthritis,alopecia areata, vitiligo, hepatitis and cholangitis,

Sjogrens syndrome, Addisons disease, peripheral neu-

ropathy, psoriasis, and autoimmune cardiomyopathy.

DIFFERENTIAL DIAGNOSIS

Because of its many and varied clinical features, CD can

be a great imitator of other disorders, and it can also be

silent. The differential diagnosis depends on the way it

manifests as well as the age of the patient (Table 186).

The presentation of diarrhea, abdominal distention,

irritability, and vomiting may mimic gastroesophageal

reflux, milk or soy protein allergy, Giardia infection,malrotation, lymphangiectasia, and iron deficiency ane-

mia in toddlers. The same presentation in school age

children and adolescents should lead to considerations

Differential Diagnosis

Toddler School Age and Adolescent Flattened Mucosa (Villous Atrophy)

Gastroesophageal reflux Irritable bowel syndrome Malnutrition

Milk or soy protein allergy Functional abdominal pain Infectious enteropathy: GiardiaGiardia Post-infectious chronic diarrhea Tropical sprue

Lymphangiectasia Small bowel bacterial overgrowth IgA/immunodeficiency

Malrotation Immunodeficiency (IgA deficiency, HIV, other) Allergic enteropathy: cow/soy milk

Iron deficiency anemia IBD (Crohns disease) Autoimmune enteropathy

Chronic constipation/

Hirschsprungs

Growth hormone deficiency ZollingerEllison syndrome

Fibromyalgia

Acid peptic disease, ulcer

Table 186.



6/12


of irritable bowel syndrome, inflammatory bowel dis-

ease, lactose intolerance, ulcer, post-infectious diarrhea/

bacterial overgrowth, as well as parasite infection, and

immunodeficiency such as IgA deficiency or HIV. Of

note, lactose intolerance may be a consequence of the

intestinal injury of CD and often resolves with therapy.

The histological hallmark of CD is the small bowel

biopsy showing increased numbers of IELs and villous

atrophy. The differential diagnosis for this histological

finding includes HIV and immunodeficiency, allergy,

Giardia infection, viral gastroenteritis, autoimmune

enteropathy, ZollingerEllison syndrome, tropical sprue,

and malnutrition (Table 186).

DIAGNOSIS

The criteria for diagnosis of CD have been recently

updated separately by the North American Society for

Pediatric Gastroenterology, Hepatology and Nutrition

(NASPGHAN),1the Federation of International Societ-ies of Pediatric Gastroenterology Hepatology and Nutri-

tion,20 the National Institutes of Health (NIH),11 and

the American Gastroenterological Society (AGA).21,15

Unfortunately, these guidelines are not uniform. In gen-

eral, the diagnostic algorithm depends on whether the

presentation includes clinical signs or symptoms (Fig-

ure 182), or whether identified because of associated

conditions or risks (Figure 183).

The current NASPGHAN and FISPGHAN rec-

ommendations are to use TTG antibody assays or EMA

as the single screening test. These tests have sensitivity

and specificity above 0.95. The role of new serologic

tests such as the deamidated gliadin peptide antibody

test is not yet clear. There is no benefit to a celiac panel

of multiple antibody tests. Because of the rare case of

CD in a patient with IgA deficiency, and to increase the

confidence in a negative result, quantitative IgA levels

may be obtained, or IgA plus IgG-based TTG tests

ordered. AGA are no longer recommended for any

patient suspected to be at risk for CD as it has a low

specificity and high false-positive rate.

A positive serologic screening test should be fol-

lowed by a small bowel biopsy showing villous atrophy

in order to confirm the diagnosis of CD, and to exclude

other causes for the symptoms. The presence of increased

IELs alone, the Marsh 1 lesion, is commonly seen in

other conditions and experts do not consider it enough

for diagnosis of CD. Multiple biopsies (four to six)

should be taken from the second portion and distal

duodenum. Villous atrophy with increase in IELs is the

characteristic finding (Figure 184), but is not specificfor CD (see Table 186). Finally, a complete resolution

of symptoms within weeks of following a GFD clinches

the diagnosis in the child with a clinical presentation

of CD.

Value of DQ2/DQ8 Testing

Virtually all patients with CD will test positive for DQ2

or DQ 8. However, 3040% of Caucasians will express

DQ2 or DQ8, and fewer than 5% will ever develop CD.

Therefore, the value of HLA haplotype testing is in its

Clinical signs or symptoms

TTG and quantitative IgA

Biopsy consistent

with celiac disease

Gluten free diet

Biopsy uncertain

Consider repeat biopsy, trialof gluten free diet, other

diagnoses

If normal, celiac disease

unlikely, evaluate further

If abnormal, refer topediatric GI for small

bowel biopsy

FIGURE 182 Diagnostic algorithm for evaluation of the symptomatic child.



7/12


high negative predictive value. Situations to consider

DQ2/8 testing include those individuals with an unclear

diagnosis and those with a risk factor but negative initial

screening. In this situation, if testing is negative for DQ2

or DQ8, CD is unlikely.

Current recommendations for biopsy-positive indi-

viduals are to recheck TTG 6 months after initiating GFD

to measure compliance and response, as serology should

normalize during this time with good compliance. For the

asymptomatic patient, TTG should be rechecked at inter-vals of 1 year or longer. Gluten challenge and repeat biopsy

are no longer recommended if patient improves on GFD.

If the patient has been on a GFD after serologic testing but

prior to biopsy, or if the patient is receiving corticoster-

oids or immunosuppressants, biopsy results may not

reflect true level of disease. In this situation, a gluten

load of 24 weeks of a gluten-containing diet usually is

sufficient to produce typical CD changes on biopsy.

CONTROVERSIES

Stool Testing

Fecal tests for CD-associated antibodies are commer-

cially available but have not been well validated in adults

and have not been studied in children.

Rapid In-office Assays

Rapid whole blood assays for TTG are also being com-

mercialized, with as yet limited data on use in clinical

practice.

Asymptomatic, at-risk child

TTG

Biopsy consistentwith celiac disease

Consider gluten-free diet

Biopsy uncertain

Consider repeat biopsy,trial of gluten-free diet

If normal, consider re-screening every 2-3 years,sooner if clinical concerns

arise

If abnormal, either re-testto confirm, or refer topediatric GI for small

bowel biopsy

FIGURE 183 Diagnostic algorithm for evaluation of the asymptomatic child with

a risk.

FIGURE 184 Small bowel biopsy features of CD, hematoxylin and eosin stain. Panel A shows normal small bowel biopsy with tall slender

villi, 10x magnification (Marsh score 0) Panel B shows tall villi with increased numbers of intra-epithelial lymphocytes, 40x magnification (Marsh

score 1) Panel C shows total villous atrophy typical of celiac disease, 10x magnification (Marsh score 3).

A B C



8/12


9/12


(FALCPA), which took effect on January 1, 2006,

requires food labels to clearly identify eight common

food allergens: wheat, eggs, fish, milk, peanuts, shell-

fish, soybeans, and tree nuts. This law does not, how-

ever, address the use of barley (malt), rye, or oats. FAL-CPA also requires the U.S. Food and Drug

Administration to develop rules for the use of the term

gluten-free on product labels. The final ruling is still

pending, although the FDA proposal is available from

the federal register at http://www.cfsan.fda.gov/%7Elrd/

fr070123.html. The parameter for a naturally gluten-

free product is 20 ppm per serving, and for a food ren-

dered gluten-free is 200 ppm.

NEW THERAPIES UNDER

INVESTIGATION

While the only current treatment for CD is lifelong adher-ence to a GFD, several alternative treatments are currently

being investigated as possible adjunctive therapies.

Bacterial Prolyl-endopeptidases

One of the properties of gluten that makes it immuno-

genic is the ability to reach the lamina propria in large,

antigenically intact peptide fragments. This is due to

lack of native peptidases capable of cleavage of peptide

Food and Ingredient List for the Gluten-free Diet

Food Item Foods/Ingredients Allowed Foods/Ingredients to Question Foods/Ingredients Not Allowed

Pastas, potatoes,

and other

starches

Pastas made from allowed grains, rice

including white brown and wild, corn

tacos and corn tortillas, potatoes,

saifun (bean threads), rice noodles

Commercial rice and pasta mixes,

French fries, fried restaurant

foods (gluten-contaminated

grease), polenta

All pastas made from grains not

allowed, couscous, tabbouleh,

soba noodles

Fruits and fruit

products

Fresh fruit, pure fruit juices Thickened or prepared fruits and

pie fillings, dried fruit mixes, jelly

and jam

Beverages Tea (black, green, and white), coffee

(plain), pure fruit juices, cider

Soy and rice beverages, instant

tea and coffee, flavored tea and

coffee, hot cocoa, hot chocolate,

soda, sports drinks, nutritional

supplements

Malted beverages, ground

coffee with added grains

Vinegar Vinegars (apple cider, rice, wine,

and balsamic)

Flavored vinegars Malt vinegar

Condiments Salt, pepper (black, white, and red), pure

herbs, pure spices, pure flavoring

extracts, wheat-free soy sauce, cream

of tartar, pickles, honey

Ground spices, seasoning and

spice mixes, gravy cubes and

mixes, bouillon cubes and

powder, ketchup, mustard,

mustard powder, Worcestershire

sauce, salad dressings, soy

sauce, teriyaki sauce, relish

Most soy sauces contain wheat

Miscellaneous Seaweed (algin, algae, alginate),

alfalfa, aspic

Yeast, yeast flakes, bicarbonate of

soda, baking soda, baking

powder, powdered sugar,

molasses, rice paper,

confectioner sugar

Communion wafers,

brewers yeast

Non-food Lotions, creams, cosmetics, lip

gloss, lip balm, sunscreen,

toothpaste, mouthwash,

products used in dental offices,

medications: prescription

and over the counter (many

contain gluten), laxatives,

vitamins, stamps, envelopes,

and gummed labels, Play Doh,

paper mache

Table 187. (Continued)



10/12


bonds of proline residues. Currently being investigated

is the use of exogenous bacterial derived prolyl-

endopeptidases to cleave these peptides into smaller,

less immunogenic fragments prior to reaching the

lamina propria. There are published data on in vitro

and in vivo animal models, and ex vivo human T cells,

with promising results. Controlled studies in CD

patients using these enzymes are yet to be

published.2329

Inhibition of Intestinal tTG

Early work is underway at developing a site-specific

inhibitor of intestinal tTG, to prevent the local deami-dation and binding enhancement of gluten peptides.

There are potential side effects with such an inhibitor,

such as impaired wound healing and perturbation of

the extracellular matrix.30,31

DQ2/DQ8-binding Peptides

Theoretically, a compound can be formulated that will

occupy the binding groove on HLA-DQ2 or -DQ8 and

prevent gluten peptide antigen presentation. This would

effectively block the immunogenic reaction. To our

knowledge, no such compound has yet been formu-

lated.30

T-cell Silencing

Another theoretic therapy would be to stimulate

apoptosis in gluten-specific T cells, or induce toler-

ance in these T cells by targeting tolerogenic dendritic

cells. These therapies again are still in theoretic

stages.30

Cytokine Therapy

Several trials of anti-inflammatory cytokine therapy are

underway for other chronic diseases such as RA and

IBD. IL-15 antagonists have been developed by several

pharmaceutical companies for treatment of RA, but

have therapeutic potential for CD as well. IFN- antago-nists have been developed and are in phase II testing for

reduction of inflammation in IBD, but are being recog-

nized for potential in CD treatment as well. IL-10 has

been tested in both refractory CD and IBD for its poten-

tial ability to shift away from TH1 immune reaction.

Unfortunately, neither trial has so far showed any

success.30,3234

Genetically Modified Wheat

Work is currently underway to evaluate the feasibility of

engineering and cultivating a modified, gluten-free

strain of wheat that would lack immunogenic peptides.

Barriers to this would include cost, palatability, and

industrial quality of the flour derived from such a strain.

This project is in its early stages, and would not be avail-

able to the mass market for many years, if ever.

Other Possibilities

Monoclonal antibodies to the adhesion molecule integ-

rin a4 are currently being used for multiple sclerosis and

are also in phase II trials for IBD. These compounds

may have potential for CD by prevention of T-cell

migration into the lamina propria. Zonulin antagonists

are being looked at for prevention of gluten-induced

intestinal hyper-permeability. The concept of usingNGK2D antagonists to prevent the phenotypic conver-

sion of CD4 T cells to cytotoxic T cells in the intestinal

epithelium has also been raised.30

PREVENTION

With a more thorough understanding of the pathogen-

esis of CD, more emphasis may start being placed on the

prevention of development rather than treatment.

In a recent meta-analysis of breastfeeding prac-

tices and effect on CD, the authors concluded that dura-

tion of breastfeeding and breastfeeding during introduc-

tion of grains reduced future risk of CD development.35,36This is not uniformly accepted, however, and some inves-

tigators feel that breastfeeding may delay or mask, but

not prevent the development of CD.37The mechanism is

speculative, but involvement of probiotic bacteria is

thought to be important for development of tolerance to

food proteins and maintenance of intact intestinal

epithelial barrier in infancy. It is also speculated that

Celiac Disease and Gluten Sensitivity Resources

www.celiac.com: celiac and gluten-free information

www.celiac.org: Celiac Disease Foundation

www.gluten.net: Gluten Intolerance Group of North America

www.celiac.nih.gov: Celiac Disease Awareness Campaign

www.celiaccentral.org: National Foundation for Celiac

Awareness

www.celiachealth.org: Childrens Digestive Health and

Nutrition Foundation

www.americanceliac.org: American Celiac Disease Alliance

www.eatright.org: American Dietetic Association

www.csaceliacs.org: Celiac Sprue Association

www.cdhnf.org: Childrens Digestive Health and Nutrition

Foundation

Table 188.



11/12


probiotic therapy in at-risk individuals may help to pro-

mote tolerance and prevent CD.

Timing of introduction of gluten and quantity of

gluten in the diet are other controversial topics in pre-

vention of CD. Early (prior to 3 months of age) and late

(after 7 months) introduction of gluten were associated

with increased risk of CD in one prospective study.37

Several recent papers documented a four-fold rise in

incidence of CD in Sweden in children less than 2 years

old, after a significant increase in gluten intake in this

population. A later decrease in gluten consumption cor-

responded to a drop in CD.38

Prevention of infectious triggers such as rotavirus

and the subsequent effect on CD risk is another area

currently being researched. If the increased permeabil-

ity and inflammation corresponding with infection can

be avoided in at-risk individuals, perhaps breakdown of

tolerance will not occur.36,39,40

REFERENCES

1. Hill ID, Dirks MH, Liptak GS, et al. Guideline for the diag-

nosis and treatment of celiac disease in children: recom-

mendations of the North American Society for Pediatric

Gastroenterology, Hepatology and Nutrition. J Pediatr

Gastroenterol Nutr. 2005;40:119.

2. Megiorni F, Mora B, Bonamico M, et al. HLA-DQ and

susceptibility to celiac disease: evidence for gender differ-

ences and parent-of-origin effects. Am J Gastroenterol.

2008;103:9971003.

3. Cataldo F, Montalto G. Celiac disease in the developing

countries: a new and challenging public health problem.

World J Gastroenterol. 2007;13:21532159.

4. Bonamico M, Ferri M, Mariani P, et al. Serologic and

genetic markers of celiac disease: a sequential study in the

screening of first degree relatives. J Pediatr Gastroenterol

Nutr. 2006;42:150154.

5. Wolters VM, Wijmenga C. Genetic background of celiac

disease and its clinical implications. Am J Gastroenterol.

2008;103:190195.

6. Nistico L, Fagnani C, Coto I, et al. Concordance, disease

progression, and heritability of coeliac disease in Italian

twins. Gut. 2006;55:803808.

7. Kagnoff MF. Celiac disease: pathogenesis of a model

immunogenetic disease.J Clin Invest. 2007;117:4149.

8. Sollid LM. Hunting for celiac disease genes. Gastroenterol-

ogy. 2008;134:869871.

9. Catassi C, Fasano A. Celiac disease. Curr Opin Gastroen-

terol. 2008;24:687691.

10. Kemppainen T, Janatuinen E, Holm K, et al. No observedlocal immunological response at cell level after five years

of oats in adult coeliac disease. Scand J Gastroenterol.

2007;42:5459.

11. National Institutes of Health Consensus Development

Conference Statement on Celiac Disease, June 2830,

2004. Gastroenterology. 2005;128:S1S9.

12. NIH Consensus Development Conference on Celiac Dis-

ease. NIH Consens State Sci Statements. 2004;21:123.

13. Fasano A. Clinical presentation of celiac disease in the

pediatric population. Gastroenterology. 2005;128:

S68S73.

14. Troncone R, Auricchio R, Granata V. Issues related to

gluten-free diet in coeliac disease. Curr Opin Clin Nutr

Metab Care. 2008;11:329333.

15. Rostom A, Murray JA, Kagnoff MF. American Gastroen-terological Association (AGA) Institute technical review

on the diagnosis and management of celiac disease. Gas-

troenterology. 2006;131:19812002.

16. Halfdanarson TR, Litzow MR, Murray JA. Hematologic

manifestations of celiac disease. Blood. 2007;109:412421.

17. Collin P, Reunala T. Recognition and management of the

cutaneous manifestations of celiac disease: a guide for

dermatologists. Am J Clin Dermatol. 2003;4:1320.

18. Zone JJ. Skin manifestations of celiac disease. Gastroenter-

ology. 2005;128:S87S91.

19. Zanchi C, Di Leo G, Ronfani L, Martelossi S, Not T, Ven-

tura A. Bone metabolism in celiac disease. J Pediatr.

2008;153:262265.

20. Fasano A, Araya M, Bhatnagar S, et al. Federation of Inter-

national Societies of Pediatric Gastroenterology, Hepatol-

ogy, and Nutrition consensus report on celiac disease.J Pediatr Gastroenterol Nutr. 2008;47:214219.

21. AGA Institute medical position statement on the diagno-

sis and management of celiac disease. Gastroenterology.

2006;131:19771980.

22. Catassi C, Fabiani E, Iacono G, et al. A prospective, dou-

ble-blind, placebo-controlled trial to establish a safe glu-

ten threshold for patients with celiac disease. Am J Clin

Nutr. 2007;85:160166.

23. Cerf-Bensussan N, Matysiak-Budnik T, Cellier C, Heyman

M. Oral proteases: a new approach to managing coeliac

disease. Gut. 2007;56:157160.

24. Matysiak-Budnik T, Candalh C, Cellier C, et al. Limited

efficiency of prolyl-endopeptidase in the detoxification of

gliadin peptides in celiac disease. Gastroenterology.

2005;129:786796.25. Gass J, Bethune MT, Siegel M, Spencer A, Khosla C. Com-

bination enzyme therapy for gastric digestion of dietary

gluten in patients with celiac sprue. Gastroenterology.

2007;133:472480.

26. Mitea C, Havenaar R, Drijfhout JW, Edens L, Dekking L,

Koning F. Efficient degradation of gluten by a prolyl endo-

protease in a gastrointestinal model: implications for coe-

liac disease. Gut. 2008;57:2532.

27. Stepniak D, Spaenij-Dekking L, Mitea C, et al. Highly effi-

cient gluten degradation with a newly identified prolyl

endoprotease: implications for celiac disease. Am J Physiol

Gastrointest Liver Physiol. 2006;291:G621G629.

28. Marti T, Molberg O, Li Q, Gray GM, Khosla C, Sollid LM.

Prolyl endopeptidase-mediated destruction of T cell

epitopes in whole gluten: chemical and immunologicalcharacterization.J Pharmacol Exp Ther. 2005;312:1926.

29. Shan L, Marti T, Sollid LM, Gray GM, Khosla C. Com-

parative biochemical analysis of three bacterial prolyl

endopeptidases: implications for coeliac sprue. Biochem J.

2004;383:311318.

30. Sollid LM, Khosla C. Future therapeutic options for celiac

disease. Nat Clin Pract Gastroenterol Hepatol. 2005;2:

140147.



12/12


31. Schuppan D, Dieterich W. A molecular warhead and its

target: tissue transglutaminase and celiac sprue. Chem

Biol. 2003;10:199201.

32. Gianfrani C, Auricchio S, Troncone R. Possible drug tar-

gets for celiac disease. Expert Opin Ther Targets.

2006;10:601611.

33. Di Sabatino A, Ciccocioppo R, Cupelli F, et al. Epitheliumderived interleukin 15 regulates intraepithelial lymphocyte

Th1 cytokine production, cytotoxicity, and survival in

coeliac disease. Gut. 2006;55:469477.

34. Salvati VM, Mazzarella G, Gianfrani C, et al. Recombinant

human interleukin 10 suppresses gliadin dependent T cell

activation in ex vivo cultured coeliac intestinal mucosa.

Gut. 2005;54:4653.

35. Akobeng AK, Heller RF. Assessing the population impact

of low rates of breast feeding on asthma, coeliac disease

and obesity: the use of a new statistical method. Arch Dis

Child. 2007;92:483485.

36. Troncone R, Auricchio S. Rotavirus and celiac disease:

clues to the pathogenesis and perspectives on prevention.

J Pediatr Gastroenterol Nutr. 2007;44:527528.

37. Norris JM, Barriga K, Hoffenberg EJ, et al. Risk of celiac

disease autoimmunity and timing of gluten introductionin the diet of infants at increased risk of disease. JAMA.

2005;293:23432351.

38. Ivarsson A. The Swedish epidemic of coeliac disease

explored using an epidemiological approachsome les-

sons to be learnt. Best Pract Res Clin Gastroenterol.

2005;19:425440.

39. Pavone P, Nicolini E, Taibi R, Ruggieri M. Rotavirus and

celiac disease. Am J Gastroenterol. 2007;102:1831.

40. Stene LC, Honeyman MC, Hoffenberg EJ, et al. Rotavirusinfection frequency and risk of celiac disease autoimmu-

nity in early childhood: a longitudinal study. Am J Gastro-

enterol. 2006;101:23332340.

41. Sollid LM. Coeliac disease: dissecting a complex inflam-

matory disorder. Nat Rev Immunol. 2002;2:647655.

42. Hoffenberg EJ, Bao F, Eisenbarth GS, et al. Transglutami-

nase antibodies in children with a genetic risk for celiac

disease.J Pediatr. 2000;137:356360.

43. Dubois PC, van Heel DA. Translational mini-review series

on the immunogenetics of gut disease: immunogenetics

of coeliac disease. Clin Exp Immunol. 2008;153:162173.

44. Hunt KA, Zhernakova A, Turner G, et al. Newly identified

genetic risk variants for celiac disease related to the

immune response. Nat Genet. 2008;40:395402.

45. Smyth DJ, Plagnol V, Walker NM, et al. Shared and dis-

tinct genetic variants in type 1 diabetes and celiac disease.N Engl J Med. 2008;359:27672777.

Celiac Dz - Peds

Documents

Transcript of Celiac Dz - Peds