International Journal of Celiac Disease

3

Authors: Aaron Lerner, Matthias Torsten

International Journal of Celiac Disease (IJCD) is an international clinical and scientific journal that aims to cover the multiple aspects of celiac disease (CD). With the renewal of the new year of 2018, the IJCD is celebrating four years of academical publications of 170 articles. The objective recognition by the medical, paramedical and the scientific community, represented by the substantial number of articles’ views, downloads, likes and citations, is indicative of a proliferative and successful journal, at least for its first four years.

3

Authors: Caleb Bazyler, Kevin Breuel

Recent reductions in healthcare funding in the United States has pressured clinical laboratories to provide the same quality of diagnostic testing with fewer resources. Testing cascades have been developed to assist in the diagnosis of various illnesses, which use fewer tests and subsequently reduce costs. However, the cost effectiveness of a celiac disease (CD) testing cascade compared to a panel is currently unknown. Therefore, the purpose of this study was to determine if a CD testing cascade was equivalent to a panel in identifying patients deemed likely for CD, and to compare their cost effectiveness in a sample of symptomatic patients from Northeast Tennessee. A retrospective analysis using a CD testing cascade was performed on 933 outpatient samples referred to our laboratory from 2012 to 2017 with a request for a celiac disease serology panel. The seroprevalence of CD for the panel and the cascade were the same in this population (1.82%, 95% binomial confidence interval: 1.06% to 2.90%). The total cost of the CD cascade was 268% less than the cost of the panel resulting in a savings of $44,705, which translates to a savings of $47.92/patient. Based on these findings, we recommend utilization of the cascade to identify patients with likely CD. In the future, creative use of novel testing strategies can have significant contributions to healthcare reform and afford patients more cost-effective clinical diagnostic testing.

4

Authors: Sur M. Lucia, Colceriu Marius, Cornel Aldea, Sur Genel, Floca Emanuela

Celiac disease (CD), also known as gluten-sensitive enteropathy or celiac sprue, is defined as a chronic, multifactorial, immune-mediated condition affecting small intestine in genetically susceptible children and adults. Gluten-sensitive enteropathy is characterized by heterogeneous clinical manifestations of variable severity that can occur at any age. For patients with prompt diagnosis and correct treatment the prognosis is excellent. Therefore, CD needs a quick diagnosis in order to start the treatment. Because of the wide range of signs and symptoms, an accurate differential diagnosis is required.

6

Authors: Mohan Khadka

Aim: To investigate the utility of routine endoscopic distal duodenal biopsy in patients with Irritable Bowel Syndrome (IBS) for the diagnosis of Celiac Disease (CD). Method: This study was conducted at the outpatient Department of Gastroenterology at the Institute of Medicine, Tribhuvan University, Kathmandu, Nepal. One hundred patients with IBS selected by Rome III Criteria were prospectively evaluated from April 2015 through March 2016. Esophagogastroduodenoscopy (EGD) was performed on all patients, with four-quadrant distal duodenal biopsies obtained from each patient. The biopsy sections were studied for Marsh-type histology, a histology characteristic of CD. Patients with Marsh-type histology had Immunoglobulin-A anti-tissue transglutaminase (IgA anti tTG) serology ordered, were recommended to start a gluten-free diet (GFD), and were followed up in clinic in 3-6 weeks. The prevalence of CD (defined as Marsh histology grade I-III with serology positive responding to GFD) was calculated in patients with IBS as a whole and among IBS subtypes. Statistical analysis was done using SPSS version 19 software (Chicago, IL, USA). Results: Of the 100 IBS patients evaluated,50 patients had abnormal duodenal histology. Among these 50 patients, 13 had Marsh-type histology, and the remaining 37 had non-specific duodenitis. Of the 13 patients with Marsh-type histology, 4 were seropositive for CD and 9 were seronegative. The overall prevalence of CD was 4%. All 4 seropositive and 2 out of 9 seronegative patients responded to GFD in 3 to 6 weeks. Conclusion: Routine endoscopic distal duodenal biopsy is useful for the diagnosis of CD in patients with IBS as it could also detect the disease in patients with negative celiac serology.

2

Authors: Sur M Lucia, Floca Emanuela, Sur Daniel G, Lupan Iulia, Sur Genel, Samasca Gabriel, Aldea Cornel

In the accordance of readers, we are introducing a new chapter in Journal, which will consist in Clinical Scenarios for Medical Students. First clinical scenario is presented by associate professor Sur Genel and his team: a 12-year-old girl diagnosed with a combination of four autoimmune diseases: autoimmune hepatitis, thyroiditis, celiac disease and type 1 diabetes mellitus.

3

Authors: Mohammad Rostami-Nejad, Amir Sadeghi, Hamid Asadzadeh-Aghdaei, Sahar Rismantab, Mohammad Reza Zali

Some factors include environmental triggers have role in development of intestinal inflammation in inflammatory bowel disease (IBD). A number of patients with IBD, experience improvement in their gastrointestinal symptoms and disease course when avoiding gluten. To highlight this issue we present a 28years old male patient, known case of ulcerative colitis, was admitted to the hospital for a flare-up of his disease. He presented with bloody diarrhea despite the fact that he was on long term variable dose of oral and topical Asacol since 4 years ago and azathioprine 2.5mg/kg/day prescribed for his persistent symptoms since last year. In spite of drug adherence, he experienced 3 flare-ups during past year and refused receiving prednisolone. Colonoscopy demonstrated severe erythema, multiple erosions and friability through the left colon from rectum up to splenic flexure. Histopathological evaluation revealed crypt architecture distortion with moderate increase in lymphoplasmacytic infiltration as well as neutrophilic activity in the form of cryptitis and crypt abscess formation. Upper GI endoscopy followed by duodenal biopsies and serological evaluation were negative for celiac disease. Before considering anti-TNF agents, patient underwent a gluten-free diet (GFD) and with a positive response, it continued for 6 weeks. After 6 weeks GFD his bloody diarrhea was nearly resolved and 12 weeks later most of his symptoms disappeared and entered to the full clinical remission. He stopped the diet and 12 weeks later his symptoms returned and experienced another relapse that again improved on GFD.As an environmental factor, gluten represents a strong antigen that might be implicated in the pathogenesis of at least a number of patients with IBD. Dietary restriction of gluten might be useful in some IBD patients during the exacerbation of their disease.

4

Authors: Jennifer Webster, Kathy Shaw, Judy Shea, April Taylor, Ritu Verma

Celiac disease (CD) is an immune-mediated genetic disorder occurring secondary to gluten exposure and increasing the likelihood of low bone mineral density (BMD). As there are no published guidelines for dual-x-ray absorptiometry (DXA) scanning in pediatric CD patients, we characterized current practices of pediatric gastroenterologists in ordering screening DXA scans for pediatric CD patients. To accomplish this, A REDCap survey was distributed to the NASPGHAN listserv. There was a total of 231 (11%) responses. The majority (60%) of clinicians do not order screening DXA scans because they don’t believe it is clinically necessary. Patient factors influenced ordering screening DXA scans with fracture history driving ordering and tissue transglutaminase (tTG) level not affecting practice. Physician factors such as practice type and experience were not associated with ordering screening DXA scans. Case scenarios, showed wide variation in management based on DXA results.

5

Authors: Eric P. Borrelli

Celiac disease is a severe autoimmune disease that results in patients having an intolerance to gluten. Patients that have celiac disease and ingest gluten can have gastrointestinal related adverse effects. There is currently no cure or treatment for celiac disease outside of a diet consisting of strict adherence to a 100% gluten free diet. However, adherence to a strict gluten free diet is difficult and patients may consume food that is cross-contaminated with gluten which can cause adverse effects that can lead to medical treatment or hospitalizations. Currently, there is only limited published data detailing hospitalizations for celiac disease in the United States. This study analyzed trends in hospitalizations for celiac disease in the United States by utilizing the National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project net (HCUPnet) using the primary diagnosis code 579.0 celiac disease. The study analyzed total discharges, length of stay for hospitalizations from 1995-2014, as well as mean cost per hospitalizations from 2006-2014. Total number of hospital discharges for celiac disease was trending upward from 1995 to 2014 varied from a low of 391 discharges in 1996 to a high of 1405 in 2010. The mean length of stay varied from a high of 8.69 days in 1996 to a low of 4.88 days in 2014. The mean cost per hospitalization varied from a high of $11,510 in 2013 to a low of $9,247 in 2014. Until there is a cure or therapeutic treatments available, celiac disease will continue to cause hospitalizations and contribute to the cost of healthcare in the United States.

7

Authors: Elize Vis, Peer Scheepers

Research has described the perceived social restrictions that people who suffer from celiac disease can experience, but never investigated their actual amount of social contacts as compared to a healthy population. Therefore, we focus on the question whether people who suffer from celiac disease or non-celiac gluten sensitivity have less informal social capital (e.g. contacts with friends and family) than a healthy population and, if so, which health related factors can explain these differences in social capital. With the aid of the Dutch Celiac Association, we recently gathered high quality data. Results show that people who are diagnosed with celiac disease or NCGS indeed have less informal social capital than a healthy control group. This can be explained partly because the former more often suffer from depression, poor subjective health and another chronic condition. Moreover, it appears that demographic factors, such as gender, age, having children and marital status, reduce the initial relationship completely. These demographic factors thus play a more important role. As yet, these findings may help healthcare professionals to interpret social consequences of celiac disease and non-celiac gluten sensitivity in a broader sense.

2

Authors: Mohammad Rostami Nejad

Antibodies to deamidated gliadin peptides (DGP-AGA) have newly been presented into the extensive variety of serologic examinations for celiac disease (CD). In compare with the modern AGA, DGP-AGA indicated a higher sensitivity and specificity for CD and simply identified by ELISA kits. Nevertheless, even though the very favorable outcomes, DGP-AGA are not yet regularly used in the serologic checkup for CD. An antibody approach could initiate development in the diagnostic precision of serology for CD screening.

2

Authors: Hakim Rahmoune, Nada Boutrid, Mounira Amrane, Belkacem Bioud

Celiac disease is a genetically determined gluten-sensitive auto-immune condition, mainly an enteropathy resulting in nutrient malabsorption. Its intestinal damages, with lymphocytic gastroduodenitis, can also be due to a myriad of gastro-intestinal infections that act as true "triggering agents". We present two pediatric patients with infectious associations leading to a transient positive celiac disease serology, with various agents and different genetic suscpetibility.

3

Authors: Ayoub Aomari, Mohamed Firwana, Imank Benelbarhdadi, FZ. Ajana

Digestive cancers are the most severe complications of celiac disease (CD), which can lead to death. We can report 12 patients with CD associated with cancer. It is retrospective study of 12 patients with CD complicated by cancers, collected in the department of diseases of the digestive system "Medicine C", from 1995 to 2017. Six patients had lymphoma, three were gastric tumors, two were small intestine tumors, and one had liver tumor. The diagnosis of lymphoma was made at the same time as that of CD in one patient, three months later in two patients, 18 months later in two patients and 8 years later in one patient. Morphological and histological data were in favor of malignant non-Hodgkin's lymphoma with intestinal localization in four patients, with lymph node localization in one patient and one patient with refractory celiac disease type 2 with intraepithelial lymphoma. The treatment consisted of chemotherapy in four patients and corticosteroid therapy with parenteral nutrition in one patient. The evolution was marked by the death of 03 patients and 2 patients were lost without any idea about their evolution. The diagnosis of the gastric tumor was retained after the realization of a upper gastrointestinal endoscopy with biopsies. The histopathologic examination was in favor of a well-differentiated adenocarcinoma in two patients, and of an adenocarcinoma moderately differentiated in one patient. The diagnosis of the well-differentiated neuroendocrine tumor was carried out 30 years after that of CD. The patient underwent a resection of the first two duodenal portions with duodeno-jejunal anastomosis and a colonic resection with termino-terminal anastomosis. The evolution was good with a 2 years follow-up. The second patient with intestinal cancer was a moderately differentiated adenocarcinoma of intestinal origin; the diagnosis was retained after an abdominal CT scan with mass biopsy. The treatment was palliative chemotherapy, with an abdominal scan three months later showed partial response. The hepatocellular carcinoma on healthy liver was diagnosed at the same time as CD on angio-CT scan data and liver biopsy with patient death at the time of diagnosis. Digestive cancers are severe complications of CD requiring early management and follow-up of patients to reduce the rate of death.

4

Authors: Jarmila Kabátová, Rastislav Husťak

Presented analysis focuses on usefulness of consecutive celiac disease antibodies testing anti-TG2 and EMA, and HLA-DQ2/DQ8 genotyping in symptomatic children and adolescents with suspected celiac disease refered to the latest ESPGHAN guidelines (2012), that permit confirmation of celiac disease without previous duodenal biopsy. A total of 258 children and adolescents (86 male and 172 girls), aged 2 to 18 years, were retrospectively examined performance of celiac disease testing according national guidelines from 2009 included duodenal sampling and the ESPGHAN nonbiopsy criteria in a pediatric population. In applying nonbiopsy criteria to our cohort, 33,3 % (86) of symptomatic children and adolescents with such high anti-TG2 titers and positive EMA could have been initially diagnosed without an intestinal biopsy. All of them presented with advanced intestinal atrophy Marsh 2-3. Part of the rational of the study was to determine sensitivity and specificity, positive and negative predictive values of the final laboratory tests and diagnostic accuracy of the combined tests for antibodies.

9

Authors: Kayla Morrell, Melissa K. Melby

Celiac disease (CD), an autoimmune disorder triggered by gluten ingestion, negatively affects individuals’ health if left untreated. In individuals with the requisite genes, CD destroys the intestinal lining because specific peptide fragments of gluten (protein found in wheat and related grains) bind to the receptor proteins coded for by HLA-DQ2 and DQ8 genes, thereby causing an autoimmune response that damages intestinal cells and results in malnutrition. Because the disease has a genetic basis and can lead to impaired reproductive functioning and death, natural selection should lead to a decrease in CD prevalence over time. However, evidence suggesting CD increases in some populations contradicts this hypothesis, resulting in the ‘Celiac Disease Evolutionary Paradox.’ The worldwide average prevalence rate is around 1%, although rates of up to 5% have been observed in certain populations. Maintenance or increase in the frequency of CD-predisposing genes in certain populations suggests potential evolutionary benefits for those genes, which may exhibit antagonistic pleiotropy, such as being beneficial for infectious disease but detrimental for chronic disease such as CD. Recent dietary and environmental changes (including dietary gluten exposure, breastfeeding duration and the intestinal microbiome, and immune function) may have led to discordance with the Environment of Evolutionary Adaptedness, thus contributing to increases in CD. Consideration of potential benefits of CD-risk gene alleles, in conjunction with a deeper understanding of environmental factors exerting positive and negative selection on those alleles, may help to explain population variation in CD prevalence rates, and shed light on the complex gene-environment interactions influencing this devastating disease.

2

Authors: Iulia Lupan, Anamaria Girbovan, Gabriel Samasca

With all the advancements of science, genetic tests are important for the diagnosis of celiac disease but a lack of standardization is evidenced.

3

Authors: Aomari Ayoub, Mohammed Firwana, Amina Amjahdi, Anass Rahaoui, Imane Benelbarhdadi, Ajana Fatima Zahra

Introduction: Celiac disease (CD) is an autoimmune enteropathy induced by the ingestion of gluten (wheat, barley, rye). The classical form has become a minority. Currently, the most frequent forms of presentation are extradigestive with various manifestations, among others, reproductive disorders. The aim of our study is to assess the frequency of these disorders in CD and their evolution under gluten-free diet (GFD). Materials and methods: Descriptive retrospective study of 173 patients with CD followed in the department of diseases of the digestive tract "Médecine C" of the Ibn Sina Hospital in Rabat, over a period of 18 years. Result: In 173 patients with CD, 58 patients (28,9%) had reproductive disorders. There are 53 women and 5 men. The average age was 32,25 years. The diagnosis of CD is based on histology and serology. The Reproductive problems were never isolated but always associated with other digestive or extra-digestive signs at the time of diagnosis of CD. These disorders are represented by: delayed puberty in 11 patients (19%), secondary amenorrhea in 13 patients (22.4%), irregular menstrual in 12 patients (20.6%), absence of development of secondary sex characteristics in 8 patients (12.5%), spontaneous abortions in 7 patients (10.9%), menometrorrhagia in 4 patients (13.8%), primary sterility in 5 patients (8.6%), early menopause in 6 patients (10.3%), premature delivery in 3 patients (5%), primary amenorrhea in 2 patients (3.4%) and intrauterine fetal death in one case (1.7%). All our patients have had a GFD. 15 patients lost to follow-up, two patients died and 12 patients undergoing follow-up. The remaining 29 patients, the evolution of reproductive disorders under GFD was favorable in 26 patients (90%), with the normalization of cycles in 15 patients, resumption of cycles in 6 patients, development of secondary sex characteristics in 2 patients, fertility resumption in one case, initiation of cycles after primary amenorrhea in one case and delivery of a newborn at term after premature deliveries in one case. The evolution was unfavorable in 3 patients with the notion of miscarriage 4 years after the start of the GFD in one patient and the absence of cycle resumption in two patients. Conclusion: The reproductive disorders associated with CD are frequent and varied. In our study, these disorders responded very well under a GFD, conducted in 90% of patients. These disorders are thus reversible under this diet.

4

Authors: Karina Szczepanczyk, Hooman Saberinia, Faryal S. Mirza

Introduction: Patients with active celiac disease are more likely to have osteoporosis and increased risk of fractures. Studies show that gluten-free diet may help improve bone mass to some extent. Here, we report a premenopausal woman with celiac disease with progressively declining bone mineral density (BMD) into severe osteoporosis range, who demonstrated a remarkable improvement in BMD after one year of gluten-free diet and oral bisphosphonates. Clinical case: A 44-year old premenopausal female had a low screening bone density at the ankle at 39 years of age, and was confirmed to have low BMD by central DXA, with osteoporosis at the spine and osteopenia at the hips. Celiac antibodies were positive and she was recommended gluten free diet (GFD), which she stopped after a year. Her primary care also started her on supplemental calcium and vitamin D with stabilization of BMD over the next three years. Subsequent BMD 2 years later showed 7.6% decrease in bone density at the lumbar spine (T-score -3) and 5.8% decline at the total hip (T-score -2.7) and she was referred for osteoporosis evaluation. Workup revealed high bone turnover with an elevated PTH of 162pg/mL, low normal serum calcium of 8.8mg/dL, normal vitamin D levels and low urine calcium levels, suggestive of secondary hyperparathyroidism. At this time, review of systems revealed a questionable history of gluten sensitivity, but she denied any diarrhea or bloating. A duodenal biopsy revealed villous atrophy and positive antibodies against tissue transglutaminase, compatible with active celiac disease. She was started on a gluten-free diet and alendronate was also added in view of low bone density and high bone resorption. Bone density performed one year later revealed a remarkable 14.1% increase at the level of the lumbar spine and 8.9% increase at the level of total hip compared to prior BMD. Conclusion: This is the first case of such a remarkable increase in BMD on gluten-free diet and concomitant bisphosphonate use, suggesting a cumulative benefit of this strategy that is greater than using either of these interventions alone.

5

Authors: Rajae Manzali, Abderraouf El Antari, Ahmed Douaik, Mouna Taghouti, Moncef Benchekroun, Mohamed Bouksaim, Nezha Saidi

Physico-chemical, functional and antioxidant capacities of 26 oat (Avena sativa L.) lines and cultivars were investigated. The results showed that the contents were considerably variable within samples, starch concentration (44,83-63,79%), carbohydrate (42,08-62,65%), protein (9,67-17,44%), fat (3,06-10,96%), β-glucan (1,37-6,05%) and ash (1,22-5,38%). The analysis of fatty acids composition indicated that, palmitic acid, oleic acid, linoleic acid, stearic acid and linolenic were the major fatty acids in oat lipids, and that the contents of total UFA in assessed material varied between72, 29-80,11%. Moreover, the phenolic content varied from 23,1 to 56,5 mg GAE/100g, carotenoids content range from 0,98 to 4,34 μg β-carotene equivalents/g and antioxidant activity, evaluated as DPPH radical scavenging activity, from 12,2 to 46,7%. The Protein profiles showed nearly identical nature of electrophoresis patterns, indicating no eventual change in protein quality. It could be concluded here that the flour of issue from these cultivars provide health benefits and high added value, if included as an ingredient for making new functional food products to meet the demands of health conscious generation.

6

Authors: Joan Geiger, Yeong Rhee, Sherri N. Stastny, Ardith Brunt, Elizabeth Blodgett Salafia

Background: Adherence to the gluten-free diet is the only treatment for celiac disease (CD) and some patients report lack of expertise among registered dietitian nutritionists (RDNs). Objective: To measure RDN self-reported celiac disease (CD) knowledge and preferences for resources for self-education and patient education. Methods: A cross-sectional research design was used to recruit RDNs from participating state affiliates Alaska, Colorado, Connecticut, Delaware, Montana, Nebraska, and North Dakota in 2013. A 35 item internet-based survey was distributed via Survey Monkey and included Likert scale questions based on a previous RDN allergy survey. Demographic and gluten-free diet and CD multiple-choice questions were also included. Results: Four-hundred and five registered dietitians (RDNs) who volunteered from the seven participating affiliates responded to the survey. Chi-squares were used to determine frequencies and differences in responses per variable. Pearson correlation analyses were performed to determine the correlation of age, education level, years of practice, or number of CD patients seen per week and CD self-reported knowledge. RDNs reported either moderate or high levels of knowledge for all seven self-reported knowledge topics. Over 85% of RDNs selected correct answers for five CD knowledge questions. Professional and academic publications were the most commonly used resources by RDNs for self-education whereas handouts were the most commonly used resource by RDNs for patient education. Conclusion: RDNs may need more reinforcement on identification and treatment of nutritional deficiencies of CD management.

2

Authors: Lucia Sur, Emanuela Floca, Genel Sur

Autoimmune diseases in children are a big challenge for doctors. These diseases have a long evolution over time and can be associated with other autoimmune disorders. Patient transfer from pediatric to adult health care service should be done with great responsibility in order to offer quality care to patients. Juvenile idiopathic arthritis and celiac disease are two of autoimmune diseases that can have an important impact on child development.

3

Authors: Hakim Rahmoune, Nada Boutrid, Mounira Amrane, Belkacem Bioud

HLA genes have been shown to be strongly associated with a large repertoir of autoimmune diseases including Rheumatoid Arthritis (RA), Juvenile idiopathic arthritis (JIA) and Celiac Disease (CD). The present article will discuss what is the place of performing celiac disease associated serology in face of a rheumatologic patient, when gluten enteropaty is suspected. More specifically, should HLA be done prior to the serology? Unnecessary serial serological CD screening in such rheumatology patients could be avoided by performing an HLA typing, as a long-life marker of genetically CD-susceptible patients.

4

Authors: Hugh James Freeman

Celiac disease has been associated with selective IgA immunoglobulin deficiency. A celiac disease cohort of 234 biopsy-defined adults (including 73 males and 161 females) from a 30-year period from 1982 to 2011 was reviewed. A total of 7 with selective IgA immunoglobulin deficiency were noted, or about 3%. All were female with an initial positive biopsy for untreated celiac disease. All had characteristic small intestinal biopsy features of severe histopathological adult disease and additional biopsies demonstrated a histopathological response after 1 to 10 years on a strict gluten-free diet. For 6 of the 7, diagnosed at ages 24 to 40 years, follow-up biopsies were either normal or showed only minimal epithelial lymphocytosis. In addition, a 71 year old female had a limited but definite histopathological response to a gluten-free diet. Although there was no microscopic evidence for a malignant lymphoma, added biopsies for molecular gene re-arrangement studies revealed a monoclonal lymphocyte population suggesting an occult or cryptic T-cell lymphoma. Gastric and colonic biopsies showed no abnormalities or evidence of epithelial lymphocytosis. In all of those tested, IgA antibodies to tissue transglutaminase were detected, occasionally even at high levels. In these, a gluten-free diet serological response was detected. Together, these findings demonstrate a heterogeneous serological response to a gluten-free diet in adult celiac disease accompanied by selective immunoglobulin deficiency.

5

Authors: Hugh James Freeman

Celiac disease (gluten-sensitive enteropathy) is an immune mediated disorder with characteristic histopathological small bowel mucosal changes that respond to a strict gluten-free diet. Recent studies have suggested that complete (rather than partial) mucosal recovery and healing is possible, but in some this may require a more prolonged period than is currently appreciated. In this study, 182 patients (60 males, 122 females) referred for evaluation of symptoms, including diarrhea and weight loss, were selected only if initial biopsies showed characteristic inflammatory changes with severe architectural disturbance. All patients were treated with a strict gluten diet alone and diet compliance regularly monitored. Up to 90% or more of patients showed a complete mucosal response or healing. A time-dependent rate of response was noted with most patients requiring more than 1 year, and even 2 years or more, to respond, however, complete mucosal healing was still possible within 6 months. In this evaluation, females in each of 4 different age ranges had mucosal response and healing rates superior to males, while elderly celiacs had lower rates. Such factors should be considered before labeling a patient with “non-responsive” disease. However, inflammatory changes with persistent architectural disturbance, especially in celiacs with a late diagnosis and resultant late initiation of a gluten-free diet treatment, may be at increased risk for a later small bowel complication, including lymphoma.

5

Authors: Wafa Ben Saada, Fatma Derbali, Nawrez Kammoun, Raouf Hajji, Sana Triki, Monia Elleuch, Saida Zribi, Mohammed Jallali, Rim Masmoudi

Background: Celiac disease (CD) is an auto immune disease that often one or more disorders may be associated especially endocrine but also heart disorders. We report a patient case with idiopathic hypo-parathyroidism and CD revealed by pleuro-pericarditis. Observation: A 23-year-old woman was admitted in intensive care unit for epileptic-evil condition following dyspneising pleurisy. She has been diagnosed as epileptic case since 5 years and she had undergone surgery for right cataract. On the physical examination, she exhibited a tachycardia and breathing rales at pulmonary auscultation. She had clinical signs of chronic hypocalcaemia, without gastrointestinal complaints. Chest x-ray revealed cardiomegaly and right pleurisy. The cardiac ultrasound demonstrated very abundant bilateral pleural and pericardial effusion. The phosphocalcic balance resulted in a severe hypocalcemia at 0.8 mmol / l and hypo-parathyroidism was confirmed. In addition to the surgical drainage, she had calcium and vitamin D supplementation. CD was suspected after the resistance for a high supplementation and confirmed by endoscopy. Under a gluten-free diet (GFD), the evolution was marked by the stability of serum calcium levels and disappearance of pleural and pericardial effusion. Conclusion: The possibility of celiac disease should be considered in patients with hypoparathyroidism and pericarditis that seems unduly difficult to treat. This should be evaluated even in the absence of gastrointestinal symptoms.