Introduction

Chronic mesenteric ischemia (CMI) is a condition in which the mesenteric blood flow fails to meet the increased metabolic demands (1), mostly caused by atherosclerotic stenosis of the mesenteric arteries. This leads to severe postprandial abdominal pain, resulting in fear of eating and subsequent weight loss. According to the European Guidelines(2), a significant stenosis is defined as a luminal diameter reduction of ≥50% in multivessel disease and ≥70% in single-vessel disease. In the absence of a gold standard diagnostic test, treatment decisions rely on multidisciplinary consensus, which is reached based on the patient’s clinical history, presence of a significant stenosis on computed tomography angiography (CTA) and in case of single-vessel disease a functional test. The definitive diagnosis CMI is confirmed after revascularization by patient reported symptom reduction. However, prior research report clinical improvement in only 69-73%(3), suggesting possible overtreatment. Currently, radiologists manually grade a stenosis by measuring the luminal diameter reduction on cross-sectional slices. Yet, other morphological features, such as stenosis length and shape(4-6), also influence blood flow. Three-dimensional (3D) analysis of mesenteric stenosis may better reflect the hemodynamic and clinical relevance of a mesenteric artery stenosis. 3D-analysis using semi-automated segmentation tools, such as 3D Slicer, allows for more comprehensive evaluation, including cross-sectional area reduction. This study aims to compare the positive predictive value (PPV) and negative predictive value (NPV) of diagnosing definitive CMI by using semi-automated 3D segmentation based on area reduction versus the conventional luminal diameter reduction-based grading performed by radiologists.

Aims & Methods

This multicenter, retrospective study analyzed baseline CTA scans from 94 patients (CoBaGI trial 2015-2019) with a consensus diagnosis of atherosclerotic CMI who underwent endovascular treatment. The CoBaGI trial(7) was a randomized controlled trial comparing the patency of bare-metal and covered stents. Of this cohort, 72 patients had a definitive diagnosis CMI compared to 22 non-CMI patients. CTA scans were excluded if there was no arterial phase, low image quality or if centerline extraction failed. Stenoses were segmented semi-automatically by using 3D Slicer. The centerline curves of the celiac artery (CA) and superior mesenteric artery (SMA) were extracted, and minimum and maximum diameters and cross-sectional areas were measured. Diameter reduction and area reduction were calculated and used to compute the PPV and NPV for the definitive diagnosis CMI for each grading method.

Results

Of the 94 baseline CTA scans, 53 CTA scans were eligible for analysis (36 definitive CMI patients, 17 non-CMI patients). The PPV for diameter reduction graded by radiologists was 0.72 (95% CI 0.56 - 0.82), compared to 0.78 (95% CI 0.63 - 0.89) for 3D segmentation. The NPV was 0.50 (95% CI 0.24 - 0.76) for diameter reduction graded by radiologists compared to 0.56 (95% CI 0.33 - 0.77) for 3D segmentation. When applying a threshold of 75% area reduction, the PPV improved to 0.79 (95% CI 0.65 - 0.89), and the NPV to 0.80 (95% CI 0.49 - 0.94).

Conclusion

Grading a mesenteric artery stenosis by using 3D-segmentation with area reduction provides a higher PPV and NPV for diagnosing definitive CMI compared to the conventional diameter reduction based grading. These findings suggest that incorporating 3D-segmentatons could improve patient selection for revascularization and reduce unnecessary procedures.

References

1. Moawad J, Gewertz BL. Chronic mesenteric ischemia. Clinical presentation and diagnosis. Surg Clin North Am. 1997;77(2):357-69.
2. Terlouw LG, Moelker A, Abrahamsen J, Acosta S, Bakker OJ, Baumgartner I, et al. European guidelines on chronic mesenteric ischaemia - joint UEG, EAGEN, ESGAR, NVMDL, HSG, CIRSE and DMIS clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United European Gastroenterol J. 2020;8(4):371-95.
3. van Dijk LJD, Moons LMG, van Noord D, Moelker A, Verhagen HJM, Bruno MJ, Rouwet EV. Persistent symptom relief after revascularization in patients with single-artery chronic mesenteric ischemia. J Vasc Surg. 2018;68(3):779-85.
4. Mustapha N, Mandal P, Johnston P, Norsarahaida A. A numerical simulation of unsteady blood flow through multi-irregular arterial stenosis. Applied Mathematical Modelling, 34, pp 1559-1573. 2010;34.
5. Sriyab S. The Effect of Stenotic Geometry and Non-newtonian Property of Blood Flow through Arterial Stenosis. Cardiovasc Hematol Disord Drug Targets. 2020;20(1):16-30.
6. Kamangar S, Badruddin I, Ahammad N, Kalimuthu G, Nik Ghazali NN, N.J S, et al. The Influence of Geometrical Shapes of Stenosis on the Blood Flow in Stenosed Artery. Sains Malaysiana. 2017;46:1923-33.

Introduction

Detection of autoantibodies directed to tissue transglutaminase (tTG) and deamidated gliadin peptide (DGP) is important in the assessment of individuals under clinical suspicion of celiac disease (CD).

Aims & Methods

In this study, we compared the analytical performance for the detection of autoantibodies to tTG (IgA isotype), of the MosaiQ AiPlex^® CD microarray (AiPlex CD. AliveDx, Switzerland), a CE-marked, novel, single-use, fully automated, multiplexed microarray immunoassay and routine methods. De-identified serum samples, characterized as reactive or non-reactive for tTG IgA as per the routine practice method of the evaluation site (EliA™ Celikey^® IgA, Phadia AB, Sweden), were tested with the evaluated device. Although AiPlex CD features the semi-quantitative measurement of both tTG IgA and IgG and anti-deamidated gliadin peptide (DGP) IgA and IgG antibodies, and qualitative measurement of total IgA in serum; this comparison was limited to tTG IgA as no samples characterized for other CD autoantibodies were available. Positive percent agreement (PPA) and negative percent agreement (NPA) were calculated. Double-sided 95% Confidence Intervals (CI) were calculated using Clopper-Pearson Exact Method.

Results

77 samples characterized as reactive for tTG IgA by the routine method and 90 samples characterized as non-reactive for this marker were included in the analysis. The evaluated device identified 73 out of 77 samples characterized as reactive by the routine method, for a PPA of 95% (95% CI: 87.2, 98.5). Out of the four discordant samples, one also yielded a non-reactive result for tTG IgG and reactive results for both DGP IgA and IgG in the evaluated device and negative anti-endomysial antibodies (EMA) by immunofluorescence; two samples were reactive to DGP IgA or DGP IgG by the evaluated device and one sample was non-reactive to all four markers and was negative to EMA. Regarding the samples characterized as non-reactive by the routine method, the evaluated device identified 86 out of 90, for an NPA of 96% (95% CI: 89.0, 98.7). For the four samples with discordant results, the evaluated device also yielded reactive results for at least one additional CD antibody (tTG IgG, DGP IgA, DGP IgG).

Conclusion

In this study, the evaluated microarray immunoassay showed high concordance with the compared routine method for the serological assessment of tTG IgA, a key marker in the evaluation of CD.

Disclosure

This study was funded by AliveDx Suisse SA, Eysins, Switzerland. Gerber Gomez and Christian Fischer are AliveDx employees.

Introduction

Celiac disease is a chronic disease that requires lifelong treatment with a strict diet, which has an impact on the health-related quality of life of the patients.

Aims & Methods

To analyse the quality of life in patients with celiac disease that are followed in our centre.
A single-center, prospective, observational study based in the Spanish version of Celiac Disease Quality of Life Survey (CD-QOL), a validated questionnaire.

Results

53 patients agreed to complete the questionnaire. Mean age of the patients at the moment of the consultation was 39.15 years, while mean age at diagnosis of the patients who agreed to participate was 33.20 years. Of them, 35.8% had university degree, 28.3% completed professional training and 35.8% only had compulsory basic education.
Of these patients, 69.2% didn’t have any relative diagnosed with celiac disease, and only the 13.2% used to live with another celiac patient. Just 9.4% of the patients who filled in the questionnaire were members of a celiac patient society.
75.5% of the patients claimed that celiac disease affects their social life, 84.9% declared that they comply properly with the gluten-free diet, although for the 32.7% the adherence to the dietary treatment is difficult.
Of the patients who participated, 33.9% declared that they feel quite / a lot limited by the disease, 27.4% feel quite / much stigmatized because of the illness, 22.7% have quite / a lot of problems in their social life, 32.2% have quite / a lot difficulties travelling, and 22.7% of patients declared that they have quite / a lot the impression to not have a normal life.

Conclusion

1. Celiac disease may be quite burdensome even in asymptomatic patients who are not supposed to have small bowel damage in their follow-up. According to our series, up to 75.5% of patients have problems in their social life.
2. Health education during the follow-up providing greater knowledge of the disease, support from specialized nurses, and the recommendation to join patients support groups (patient societies) could be tools that may empower celiac patients to help manage their disease and enjoy a normal life.

References

1. Al-Toma A, Volta U, Auricchio R, et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J 2019;7(5):583-613.
2. Casellas F, Rodrigo L, Molina-Infante J, et al. Transcultural adaptation and validation of the Celiac Disease Quality of Life (CD-QOL) Survey, a specific questionnaire to measure quality of life in patients with celiac disease. Rev Esp Enferm Dig 2013; 105(10):585-93.

Introduction

Coeliac disease (CD) affects 1% of the population in the United Kingdom (U.K.) but is often underdiagnosed¹. Complications of CD include detrimental effects on bone health and increased fracture risk². Currently, evidence supporting routine serological testing for CD in adults with fractures is limited.

Aims & Methods

The aims of this study were to:
1. Determine whether the prevalence of CD among adult fracture patients exceeds the expected 1% in the general population.
2. Characterise demographic and fracture‑site patterns to identify high‑risk subgroups.
This cross-sectional observational study was conducted at a single U.K. fracture clinic with 1000 adults (≥16 years) with a fracture recruited between April 2023 and April 2025. Patients under 16 or unable to provide consent were excluded. Patients with known CD were included. Demographic data (age, gender, ethnicity) and fracture sites were recorded. Anti-tissue transglutaminase antibody (tTG-IgA) tests were performed unless known to have CD. Equivocal tTG-IgA results were reviewed by a gastroenterologist, and repeat testing was conducted if needed. Seropositive participants were invited for duodenal biopsy. Laboratory processing issues were treated as negative results. Statistical analyses included descriptive demographic analyses and prevalence calculations.

Results

Baseline characteristics are summarised in Table 1. Of 1000 participants, 978 participants underwent tTG-IgA testing, of which 5 participants tested positive, yielding a seroprevalence of 5/1000 (0.5%). Duodenal biopsy confirmed CD in 2 participants 2/1000 (0.2%), while 1 seropositive participant did not attend biopsy, 1 is awaiting biopsy, and 1 had a negative biopsy. 28 participants were classified as having negative results. This group included untested samples (n=15), equivocal results (n=6), and known CD (n=7). The overall prevalence of CD in our study population was 9/1000 (0.9%): 7 known and 2 newly confirmed CD. The CD population were predominantly white, and upper limb fractures were most common, aligning with prior studies^3,4.

Table 1

Conclusion

This represents one of the largest evaluations of CD prevalence in fracture patients. The observed prevalence of CD 9/1000 (0.9%) closely aligns to the expected UK prevalence for CD. However, given only 5/1000 (0.5%) tested positive serologically and 2/1000 (0.2%) confirmed through biopsy, these findings suggest that routine screening in fracture clinics is unlikely to be efficient. Instead, we should explore targeted screening in fracture clinics, reserving testing for patients with iron‑deficiency anaemia, chronic GI symptoms, or a first‑degree family history of coeliac disease.

References

1. West J, Logan RF, Hill PG, Lloyd A, Lewis S, Hubbard R, Reader R, Holmes GK, Khaw KT. Seroprevalence, correlates, and characteristics of undetected coeliac disease in England. Gut. 2003 Jul;52(7):960-5. doi: 10.1136/gut.52.7.960. PMID: 12801951; PMCID: PMC1773707.
2. Heikkilä K, Pearce J, Mäki M, Kaukinen K. Celiac disease and bone fractures: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2015 Jan;100(1):25-34. doi: 10.1210/jc.2014-1858. PMID: 25279497.
3. Thomason, K., West, J., Logan, R. F., Coupland, C., & Holmes, G. K. (2003). Fracture experience of patients with coeliac disease: a population based survey. Gut, 52(4), 518–522. https://doi.org/10.1136/gut.52.4.518
4. Mardini, H. E., Westgate, P., & Grigorian, A. Y. (2015). Racial Differences in the Prevalence of Celiac Disease in the US Population: National Health and Nutrition Examination Survey (NHANES) 2009-2012. Digestive diseases and sciences, 60(6), 1738–1742. https://doi.org/10.1007/s10620-014-3514-7

Introduction

Interpretation of duodenal biopsies in celiac disease (CeD) is receiving attention in clinical practice and clinical trials, where follow up biopsies are obtained to assess CeD activity or response to interventions. Follow up biopsies are likely to increase once therapeutics are approved, to determine eligibililty. While CeD research pathologists employ defined histologic protocols in grading celiac disease injury, diagnostic practices of non-CeD focused gastrointestinal pathologists(GI) are unknown.

Aims & Methods

A 19-question survey was distributed to 489 United States based GI pathologists. Topics included demographics, approach to diagnosis, reporting preferences and availability/attitudes towards digital pathology. A follow up survey of micrographs of duodenal mucosal biopsies was then distributed. Respondents were asked to comment on adequacy of mucosal orientation to assess architecture and to score villous blunting in celiac disease/control biopsies.

Results

There were143 responses (29%). See Table 1 for detailed responses for Demographics, Pathology Assessment, Reporting and Digital Pathology Status. 65% evaluate >25 biopsies per week. Quality of biopsy orientation was defined by 87% of respondents as the presence of at least 3 oriented villous-crypt units. 76% stated that inadequate orientation occurs in only a minority of samples (<25%), yet the ability of respondents to recognize poorly oriented biopsies was limited in the examples shown in the follow up survey. When presented with histology images, 93% of respondents correctly stated that a well-oriented example biopsy was adequate to evaluate villous architecture. However, only 24% of respondents recognized that a second image with no evaluable villous-crypt units was inadequately oriented, and would therefore be unevaluable for grading villous architecture. 15% review existing prior biopsy slides routinely, while 46% review existing prior biopsies when specifically requested to do so. Respondent inter-observer agreement on villous blunting scores on biopsy images was best in the setting of normal mucosa or severe villous blunting, and decreased in the setting of mild to moderate blunting. 44% would welcome software assisted digital sign out with villous height: crypt depth and intraepithelial lymphocytes (IEL) measuring tools, provided it would not increase sign out time by more than 1-2 minutes per case.

Table 1:

Conclusion

Among 143 US GI pathologists, there is significant heterogeneity in CeD pathology reporting. Respondents likely overestimate the adequacy of biopsy orientation in routine sections, which affects assessments of villous architecture. Interobserver variation was noted in architecture scores in 6 examples. Digital pathology has not been implemented in most practices. Challenges and resistance to employing online measuring tools was expressed. These data reveal opportunities for improvement in pathologist's approach to CeD biopsy interpretation.

References

Robert ME, Ciacci C, Lebwhol B. Gastroenterology. 2024 PMID: 38302007.

Disclosure

Dr. Robert consults for Takeda, Anokion, Teva, Alimentiv, PathAI and receives research salary support from Astra-Zeneca. Dr. Murray consults for Cour, Takeda and Johnson and Johnson. Dr. Leffler receives salary support from Takeda.