Up to a third of patients with coeliac disease fail to have a symptomatic response to a gluten-free diet (GFD), or relapse after initial response. Causes include inadvertent gluten exposure and complications of coeliac disease such as lymphoma. There are limited published data assessing the role of capsule endoscopy (CE) in patients with coeliac disease and persisting symptoms. For this reason we evaluated our experience of CE in this group of coeliac patients.
Methods
Data from all patients with established, biopsy-proven coeliac disease and persisting symptoms despite 12 months GFD, who underwent CE between 2004 and 2011 in a tertiary gastroenterology department were analysed. Concurrently we performed serology (endomysial antibody [EMA] and tissue transglutaminase [tTG]), and a duodenal biopsy (Marsh grading, and where appropriate T cell clonality). At CE changes of coeliac disease such as scalloping, mosaic pattern and loss of folds were assessed including extent of disease (proximal or diffuse). Concordance between serology, histology and CE was assessed using Spearman9s coefficient.
Results
69 patients (47 female, median age 56 years, range 22–83 y) were identified. 8/69 (13.0%) had significantly abnormal CE findings with either mass lesions, extensive disease or ulceration. In these eight cases: two had enteropathy associated lymphoma (EATL), four Type 1 refractory disease, one fibroepithelial polyp, one had ulcerative jejunitis. Of the 4 (4/69, 5.8%) refractory Type 1 cases, two were started on immunosuppressants, one died of unrelated causes and another was a tertiary referral case in whom outcome data are unknown. There was no correlation between the likelihood of having complicated coeliac disease and the serological titres (either a positive EMA or significantly raised tTG). However, there was a positive correlation between more extensive changes at CE (diffuse) and the level of tTG (r=0.448, p=0.001). A similar observation was made for the relationship between diffuse involvement at CE and EMA positivity (r=0.351, p=0.003). There was also a correlation between the extent of disease observed at CE and histology (r=0.455, p<0.0001).
Conclusion
This is the largest internationally reported series demonstrating a role for CE in coeliac disease patients with persisting symptoms. A significant proportion are found to have complicated or refractory coeliac disease. Extensive changes of coeliac disease seen on CE should prompt clinicians to investigate for refractory disease, request PCR on duodenal biopsy (for monoclonality) and consider immunosuppressive therapy.
Chromoendoscopy is increasingly being used to detect, localise and characterise mucosal abnormalities seen at gastrointestinal endoscopy. The endoscopic features of coeliac disease may be difficult to recognise and are reported to lack sensitivity and/or specificity. Thus many UK centres undertake routine duodenal biopsy or have a low threshold for duodenal biopsy in order to ensure detection of patients with coeliac disease. Other than one Italian investigator group there has been limited work evaluating the role of duodenal dye spray in patients undergoing endoscopy. We aimed to determine if dye spray improved identification of characteristic endoscopic markers of coeliac disease and whether this would enhance a biopsy avoidance strategy.
Methods
Patients undergoing oesophogastroduodenoscopy (OGD) with duodenal biopsies were prospectively recruited between January and November 2011. Four experienced endoscopists undertook the endoscopic examinations, with endoscopic findings reported both before and after the use of indigo carmine dye spray in the second part of the duodenum (D2). Endoscopic markers reported suggestive of coeliac disease included reduction or absence of duodenal folds, scalloping, mosaic pattern, visible blood vessels and nodularity of the duodenal folds. Thereafter, in accordance with the current gold standard four duodenal biopsies were taken and histology compared with reported endoscopic findings.
Results
83 patients were recruited (55 female: 28 male, median age 49 years). Of these, 33 (40%) had coeliac disease (24 newly diagnosed, nine previously treated) and 50 were controls. Three of the treated coeliac patients had persistent Marsh 3a–3c changes. In patients with coeliac disease (n=33), endoscopic features of coeliac disease were identified in 16/33 (48%) of patients. The addition of dye spray in D2 accentuated these features but only highlighted endoscopic markers in two further cases (18/33, 55%), which was not statistically significant (p=0.81). However, a significant difference was identified when comparing endoscopic markers in the coeliac group with the control group (p<0.001), both before and after the use of dye spray (Abstract PWE-121 table 1). Sensitivity, specificity, positive and negative predictive values of chromoendoscopy to detect coeliac disease were 55%, 100%, 100% and 77% respectively.
Conclusion
The preliminary data from this study suggests there is no additional benefit of using dye spray in patients with suspected coeliac disease. Our data suggests that our current practice of a low threshold for duodenal biopsy may still be the optimal way of diagnosing patients with coeliac disease due to the low sensitivity of endoscopic markers.
Pancreatic disease can be subtle particularly in the early stages and therefore may be missed. Symptoms of pancreatic disease are not specific and therefore patients may present to gastrointestinal (GI) services but be incorrectly diagnosed with an alternative disorder. The authors analysed a large cohort of patients referred to our unit for investigation of GI symptoms to try to identify predictors of pancreatic disease and the utility of faecal elastase-1 (Fel-1) as a marker of pancreatic disease.
Methods
A database of patients referred to our unit between January 2005 to June 2009 for investigation of GI symptoms was examined. This database included demographics, reason for referral, bowel frequency, Fel-1 level, abdominal imaging findings and final diagnosis. Fel-1 was considered abnormal below 200 μg/g stool. Using this cut off univariate analysis was performed to identify potential predictors of pancreatic disease. Variables with a p value <0.1 were entered into a logistic regression.
Results
621 patients (mean age 48.1, 224 males) were analysed. The majority had been referred for abdominal pain (n=125), diarrhoea (n=426) or weight loss (n=46). The prevalence of abnormal Fel-1 was 55/621 (8.9%, 6.7–11.4). The prevalence of a low faecal elastase-1 in patients with abdominal pain was 7/125 (5.6%), diarrhoea 36/426 (8.5%) and weight loss 4/46 (13.0%). The prevalence of abnormal pancreatic imaging was 12/55 (21.8%, 11.8–35.0). Univariate analysis showed Fel-1<200 to be associated with male gender (OR 1.4), age >50 (OR 2.4) and diabetes (OR 4.6). On multivariate analysis only age and diabetes were independent risk factors. The sensitivity, specificity, positive predictive value and negative predictive value for Fel-1<200 was 100%, 92.9%, 21% and 100% respectively. Receiver operating characteristic curve analysis showed that Fel-1<200 had an area under the curve of 0.97 (0.95–0.99, p=0.008).
Conclusion
Exocrine pancreatic disease is a common problem in patients referred to GI services and is associated with increasing age and the presence of diabetes. Fel-1 accurately identifies those patients with underlying pancreatic disease. The authors would suggest that Fel-1 should be performed routinely in patients presenting to a general luminal gastroenterology service with symptoms of abdominal pain, diarrhoea and particularly weight loss.
An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Historically, the gold standard for diagnosing small intestinal bacterial overgrowth (SIBO) has been quantitative culture of jejunal aspirate. However this test is costly and invasive. More commonly in clinical practice the glucose hydrogen breath test (GHBT) is used. We aimed to determine which clinical features and baseline laboratory investigations indicate a high likelihood of SIBO as defined by positive GHBT.
Methods
We undertook a retrospective analysis of records for all patients referred for GHBT at a single teaching hospital over a 13-year period 1998–2010. Data collected included age, sex, baseline and peak hydrogen levels, previous surgical procedures, comorbidities, haemoglobin levels, vitamin B12, folate, ferritin and albumin levels. A positive result was a rise in hydrogen of at least 20 ppm, or methane of 12 ppm, over the baseline for each gas.
Results
447 patients were identified (120 male, median age 56 years, range 17–90). Overall 84/447 (18.8%) of tests were positive. The patient characteristics associated with a positive result were concurrent use of proton pump inhibitor (PPI) (p=0.0005), previous partial gastrectomy (p<0.0001), previous right hemicolectomy (p=0.0004), and age over 75 tears p<0.0001. The laboratory investigations predictive of a positive result were low vitamin B12 (p=0.02) and low albumin <30 g/dl (p=0.03).
Conclusion
This is the largest single centre study of factors predictive of SIBO as defined by positive GHBT. Use of proton pump inhibitor, partial gastrectomy, right hemicolectomy, age over 75 years, low vitamin B12 and low albumin were predictive of SIBO.
Introduction It is thought that a “second hit” is required to trigger coeliac disease in genetically susceptible individuals. Various infective agents have been postulated as the second hit but there is little evidence to support this. We aimed to establish the recall rate of antecedent gastrointestinal infection in patients with coeliac disease, and the prevalence of undetected coeliac disease in those with stool culture proven gastroenteritis. Methods Group A comprised histologically proven patients with coeliac disease (n=233, 61 male, median 60 years) who were asked to complete a validated questionnaire and then compared to healthy controls (n=219, 79 male, median 46 years), and controls with inflammatory bowel disease (IBD) (n=196, 124 males, median 56 years). Group B were patients with stool culture proven gastroenteritis (n=101, 48 males, median 57 years) who underwent serologic testing for coeliac disease (endomysial antibody [EMA], tissue transglutaminase [tTG], immunoglobulin A [IgA]). They were compared with healthy controls (n=1200, 447 male, median 46 years). Those with positive serology underwent endoscopy and duodenal biopsy. Results In Group A 69/233 (29.6%) with coeliac disease, and 53/196 (27.1%) with IBD reported having a gastrointestinal infection within the 12 months prior to diagnosis. In both diseases this was significantly greater than in healthy controls 15/219 (6.8%) (p<0.0001). In Group B 94/101 (93%) were coeliac antibody negative. The demographics, serology and biopsy results of the seven stool-culture positive subjects with positive coeliac serology are shown in [Abstract PWE-114 table 1][1]. The prevalence of coeliac disease in patients with stool culture positive gastroenteritis was 2.97%. This was higher than in healthy controls (12/1200, 1%) (p=0.10). In Group B the gastroenteritis pathogen was identified as Campylobacter species in 96/101 (95.0%), Salmonella species in 4/101 (4.0%), and Shigella in 1/101 (1.0%). One participant had IgA deficiency. This individual had normal IgG titres, IgG EMA and IgG tTG. View this table: Abstract PWE-114 Table 1 Conclusion Patients with coeliac disease have a recall rate of previous gastrointestinal infection similar to those with inflammatory bowel disease, and significantly greater than healthy controls. In coeliac disease gastrointestinal infection may well be the “second hit” required to trigger disease but further work is required. Competing interests None declared. [1]: #T1
In an experimental session entitled Co-Producing Mobilities held at the 2014 Royal Geographical Society-Institute of British Geographers Annual Conference, 20 mobility scholars travelled around London on foot, by bus and by Tube to investigate how mobilities could be considered co-produced. In this paper, 18 participants reflect on this collaborative experiment and on how it influenced their thinking about mobilities, geographical knowledge and pedagogy. Contributions cast light on the function of conferences and the multiple forms of pedagogy they enable, and provide guiding resources for those now wanting to continue such experiments.
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)