Introduction

The exact molecular pathways contributing to epithelial abnormalities in celiac disease (CeD) remain incompletely understood. Cellular senescence, characterized by cell-cycle arrest and involving oxidative stress (OS), has been associated with the onset of chronic diseases, and attributed to the decline in regenerative capacity and the release of inflammatory agents. However, the potential involvement of senescence and OS in the context of intestinal mucosal damage in CeD remains to be investigated.

Aims & Methods

Aim: To investigate the presence of senescence and OS markers in the duodenal mucosa of both CeD patients and non-CeD controls.
Methods: This was an exploratory study wherein we analyzed duodenal biopsies obtained from 4 adult patients diagnosed with CeD and 5 non-CeD controls. Senescence was analyzed through the expression of the protein p21 and its relevance in terms of cell proliferation was evaluated by the expression of the protein Ki67 (detection with specific primary antibodies and peroxidase immunostaining). Positive cells were semi-quantified in the surface epithelium and crypts according to the percentage of positive cells among the total cells of the analyzed section (no staining reaction = 0; 1-30% stained nuclei = 1; 31–60% = 2; > 60%= 3). Carbonylated proteins were detected using amino-oxyfunctionalized fluorophores. The intensity of fluorescence was quantified in villi and crypts and expressed as relative fluorescence units (RFU) by surface. The statistical analysis was performed by non-parametric tests.

Results

Intestinal biopsies from CeD patients (3 females; median age 26.5 yr; 25%-75% IQR: 21-29) and non-CeD controls (3 females; median age 38 yr; 25%-75% IQR: 33-38) were studied. The percentage of p21-positive cells in the surface epithelium was not different between CeD patients and controls (median [25-75% IQR]): 100% (95-100%) vs 98% (98-100%), respectively (p=0.6). By contrast, the expression of p21 in the epithelium of crypts was significantly higher in CeD patients vs. controls (45% [40-67.5%] and (0 [0-1]), respectively (p=0.02). Ki-67 expression in the surface epithelium was higher in CeD patients vs. controls (2% [2-3]) and 0% [0–0%]), respectively (p=0.04), while the determinations were similar in the crypts of both groups. Finally, carbonylated proteins were detected with greater intensity in CeD patients compared to controls both in the surface epithelium (5050 RFU [3862-5622]) vs. 2335 RFU [2324-2477]), respectively (p=0.03), and in crypts (2260 RFU [2197-2598]) vs. (1403 RFU 1313-1476]), respectively (p=0.03).

Conclusion

This exploratory study presents the first evidence of senescence and OS in the duodenal mucosa of CeD patients at diagnosis and compared to controls suggesting that these phenomena could be involved in a dysfunctional epithelial regenerative process in CeD. These novel findings offer new perspectives for understanding CeD mucosal damage. However, further confirmation in a larger series of cases is required to validate these findings.

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.

Introduction

Celiac disease (CD) is an autoimmune enteropathy induced by the ingestion of gluten in genetically predisposed individuals. Although its clinical expression is most often digestive, extra-digestive manifestations can occur, among which thromboembolic complications, although rare, deserve particular attention.
The aim of this study is to describe the profiles of coeliac patients with thromboembolic complications, analyze their clinical, paraclinical and etiological characteristics, and discuss the underlying pathophysiological mechanisms.

Aims & Methods

This is a retrospective, descriptive, monocentric study conducted in the hepato-gastroenterology department of Ibn Sina Hospital in Rabat over a 30-year period, from 1995 to 2025. The records of 344 patients followed for celiac disease were reviewed. Patients with one or more documented thromboembolic complications during follow-up were included in the study. Clinical, biological, endoscopic and histological data were collected and analyzed.

Results

Of a total of 344 patients followed for celiac disease in the department, 5.5% (n=19) developed a thromboembolic complication during follow-up. The population concerned was predominantly female, with 89.5% women (n=17) versus only 10.5% men (n=2). The mean age at the time of complication was 39.6 years, with a median of 35.5 years, and extremes ranging from 18 to 62 years.
Endoscopic exploration (oesogastro duodenal fibroscopy) in these patients showed lesions suggestive of celiac disease in 68.4% (n=12), while it was non-specific in 31.6% (n=6), and normal in 5.3% (n=1). Histologically, villous atrophy was found in all patients, with 78.9% (n=15) showing total atrophy (Marsh IIIc) and 21.1% (n=4) subtotal atrophy (Marsh IIIb).
As regards thromboembolic manifestations, portal vein thrombosis was the most frequent complication, observed in 57.9% of cases (n=11). It was followed by deep vein thrombosis of the lower limbs, reported in 15.8% of cases (n=3), and ischemic stroke in 10.5% (n=2). Isolated cases of thrombosis of the inferior vena cava, axillary vein and femoral vein were recorded, each accounting for 5.3% of cases (n=1).
The etiological study revealed hyperhomocysteinemia in 36.8% of patients (n=7) and protein C and/or S deficiency in 21.1% (n=4). In the remaining 42.1% of patients (n=8), the thrombophilia work-up was normal, suggesting that celiac disease itself was the cause of the thrombotic event.
Therapeutically, all patients were treated with oral anticoagulation. One patient required a vena cava filter because of the risk of bleeding on anticoagulation, and another underwent surgical treatment for axillary thrombosis. The outcome was favorable in all cases, with no recurrence or major complication during follow-up.

Conclusion

Thromboembolic complications in celiac disease are rare but potentially serious. This study highlights the predominance of women, the diversity of thrombotic localizations, and the possible involvement of hyperhomocysteinemia and C/S protein deficiencies. In almost half the cases, no thrombophilic cause has been identified, suggesting a role for celiac disease in the genesis of these events. Clinical vigilance is essential, particularly in cases of late diagnosis or poor compliance with the gluten-free diet.

Introduction

Several studies have proposed a non-biopsy serological diagnosis of celiac disease (CeD) based on the sequential detection of anti-tissue transglutaminase (tTG) IgA and follow-up with anti-endomysial IgA as a confirmatory test or, more recently, using one test, the tTG IgA at cut-off values ≥10 UNL in both children and adults. However, while the non-biopsy strategy was well received by pediatricians, gastroenterologists still raise concerns about adopting such a strategy for diagnosing CeD in adults, especially in a non-expert setting.

Aims & Methods

The study aimed to assess the performance and clinical utility of the concurrent detection of two autoantibodies targeting two independent antigens, tTG and deamidated gliadin peptides (DGP), as an effective alternative approach for a non-biopsy diagnosis of CeD in adults with high pre-test probability.
This prospective, multicenter, binational study collected consecutive patients with a high pre-test probability for CeD. Between 2018 and 2020, adults were enrolled at four Italian and one Argentinian centers. Patients underwent evaluation for serology and duodenal biopsy at local centers. Serology was also blindly analyzed by a central laboratory (Werfen, San Diego, USA) for tTG IgA and DGP IgG by Aptiva Particle Multi-Analyte Technology (PMAT) assays. CeD diagnosis required histological confirmation of Marsh 3 damage.

Results

181 adult patients with suspected CeD were enrolled (134 with histological diagnosis of CeD and 47 not histologically confirmed as CeD). The sensitivities of tTG IgA and DGP IgG were 98.5 and 93.3%, respectively. Patients positive for both tTG IgA and DGP IgG (double positive) were predictive of CeD in 92.5% of patients at >1x upper limit of normal (ULN). Double positivity for tTG IgA and DGP IgG, both at >10x ULN, had a 100% positive predictive value for the presence of Marsh 3 histology.

Conclusion

The presence of both tTG IgA and DGP IgG at concentrations >10x ULN was 100% predictive of CeD. Incorporating DGP IgG alongside tTG IgA in a single-step approach can be considered a valid confirmatory strategy for definitive non-biopsy diagnosis of CeD, particularly for patients with high pretest probability, even in non-expert settings.

References

Ciacci C et al Serum anti-tissue transglutaminase IgA and prediction of duodenal villous atrophy in adults with suspected coeliac disease without IgA deficiency (Bi.A.CeD): a multicentre, prospective cohort study. Lancet Gastroenterol Hepatol. 2023 Nov;8(11):1005-1014.

Disclosure

FZ served as a speaker for Werfen and a consultant for Takeda. CC served as a speaker for Werfen and Takeda. GLN was employee of Werfen at time of study. JB JCB was consultant for Takeda. All other authors declared no conflict of interest.

Introduction

Fatigue, defined as “an overwhelming sense of tiredness, lack of energy and feeling of exhaustion” [1] is a frequent complaint in celiac disease. A strict, lifelong gluten free diet is the only established treatment for celiac disease, however its long-term effect on fatigue is unknown.

Aims & Methods

Our aims were to investigate the course of fatigue severity and prevalence in celiac patients from diagnosis to five to seven years on a gluten free diet, and to investigate whether diet adherence, disease activity and selected biochemical markers are associated with fatigue.
We conducted a single-center prospective study in 45 patients with newly diagnosed celiac disease. The primary endpoints were fatigue severity, as measured by the Fatigue Severity Scale (FSS) [2], the fatigue Visual Analog Scale (fVAS) [3], and the Vitality subscale of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36vs) [4]. SF-36vs scores were inverted (100 – SF-36vs = inverted SF-36vs) to ease comparison between the other scales, so that higher scores indicate more fatigue. Clinically relevant fatigue was defined by an FSS score of ≥4, a fVAS score of ≥50, and an inverted SF-36vs score of ≥65. Study visits were performed at the time of diagnosis (Visit 1), after adhering to a gluten free diet for one year (Visit 2) and for five to seven years (Visit 3). Diet adherence was evaluated through urinary gluten immunogenic peptides (GIP) and the Celiac Diet Adherence test (CDAT) [5]. Disease activity was assessed through Celiac Symptom Index (CSI) [6], celiac autoantibodies (anti tissue transglutaminase IgA and deamidated gliadin peptide IgG) and histologic evaluation (Marsh score). Nutritional status was assessed through BMI, hemoglobin, 25-hydroxy vitamin D, cobalamin, ferritin and folic acid levels.

Results

Fatigue severity was significantly reduced from time of diagnosis, for all three instruments (Table 1). Fatigue prevalence rates were significantly decreased from Visit 1 (40-53%) to Visit 3 (27-31%). Fatigue was significantly lower in patients with good adherence compared to patients with poor adherence according to CDAT scores (For FSS p=0.022, fVAS p=0.017, and for inverted SF-36vs p=0.033). There was however no difference in fatigue severity between adherent and nonadherent patients when evaluating adherence through urinary GIP. Fatigue was lower in patients in clinical remission according to CSI scores (for FSS p=0.002, fVAS p=0.004, and for inverted SF-36vs p=0.002), but not associated with autoantibodies or nutritional status. In multiple linear regression analysis, depression was the only independent variable significantly associated with all three fatigue measures at Visit 3, whereas pain was positively associated with inverted SF-36vs scores.

Table 1.

Conclusion

Fatigue remains a frequent complaint in celiac disease even after five to seven years on a gluten free diet. However, fatigue severity is reduced from time of diagnosis. Fatigue was associated with dietary adherence as assessed by CDAT. Disease activity according to CSI was associated with fatigue, whereas nutritional status, autoantibodies and histologic changes were not.

References

1. Krupp, L.B. and D.A. Pollina, Mechanisms and management of fatigue in progressive neurological disorders. Curr Opin Neurol, 1996. 9(6): p. 456-60.
2. Krupp, L.B., et al., The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol, 1989. 46(10): p. 1121-3.
3. Wolfe, F., Michaud K, Pincus T, Preliminary evaluation of a visual analog function scale for use in rheumatoid arthritis. J Rheumatol, 2005. 32(7): p. 1261-6.
4. Ware, J.E., Jr. and C.D. Sherbourne, The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care, 1992. 30(6): p. 473-83.
5. Leffler, D.A., et al., A simple validated gluten-free diet adherence survey for adults with celiac disease. Clin Gastroenterol Hepatol, 2009. 7(5): p. 530-6, 536.e1-2.
6. Leffler, D.A., et al., A validated disease-specific symptom index for adults with celiac disease. Clin Gastroenterol Hepatol, 2009. 7(12): p. 1328-34, 1334.e1-3.

Disclosure

Berit Mære Skjellerudsveen: Received lecture honoraria from Takeda for lectures on IBD and pregnancy. This study is partly funded by a grant from the patient organization “The Norwegian Coeliac Society”.