Post by kickingfrog on Feb 29, 2012 18:59:58 GMT
Gastrointest Endosc Clin N Am.
2006 Apr;16(2):317-27.
Monitoring nonresponsive patients who have celiac disease.
Krauss N, Schuppan D.
Source
Department of Medicine I (Gastroenterology, Hepatology, Pneumonology and Endocrinology), University Hospital, Ulmenweg 18, Erlangen 91054, Germany. Norbert.Krauss@med1.imed.uni-erlangen.de
Abstract
....The major cause of failure to respond to a gluten-free diet is continuing ingestion of gluten, but other underlying diseases must be considered.
Many different drugs (eg, anti-tumor necrosis factor [TNF]-alpha) have been used in patients who have RCD ...{Refractory CD}
Steroid treatment has been reported to be effective even in patients who have underlying early EATL{Enteropathy-Associated T-cell Lymphoma}.
Histologic recovery in patients who have celiac disease usually takes several months but can take up to 1 year, even if the patient remains on a strict gluten-free diet.
Some patients report celiac-related symptoms for months after a single gluten intake.
The definitions for RCD in literature vary. The authors consider the definition give by Daum and colleagues ... suitable.
They defined true RCD as villous atrophy with crypt hyperplasia and increased IELs persisting for more than 12 months in spite of a strict gluten-free diet.
If a patient is not responding well to a gluten-free diet, three considerations are necessary: (1) the initial diagnosis of celiac disease must be reassessed;(2) the patient should be sent to a dietician to check for errors in diet or compliance problems, because problems with the gluten-free diet are the most important cause for persisting symptoms; (3) other reasons for persisting symptoms (eg, pancreatic insufficiency, irritable bowel syndrome, bacterial overgrowth, lymphocytic colitis, collagenous colitis, ulcerative jejunitis, protein-losing enteropathy,T-cell lymphoma, fructose intolerance, cavitating lymphadenopathy, and tropical sprue) should be considered.
Other causes for villous atrophy are Crohn's disease, collagenous sprue, and autoimmune enteropathy. Abdulkarim and colleagues ...examined 55 patients who had a diagnosis of nonresponsive celiac disease.
He found that 6 did not have celiac disease, and 25 still had some gluten ingestion.
Tursi and colleagues ... reported 15 patients who had celiac disease with persisting symptoms.
Because histology improved in all patients after several months, RCD was excluded. Of the 15 patients, 10 had small intestinal bacterial overgrowth, 2 showed lactose malabsorption causing the described symptoms, 1 had mistakenly taken an antibiotic containing gluten, and 1 patient each had Giardia lamblia and Ascaris lumbricoides. Thus, other entities must be considered in patients who have celiac disease and ongoing symptoms.....
*************
The American Journal of Gastroenterology ,
(9 February 2010) | doi:10.1038/ajg.2010.10
Mucosal Recovery and Mortality in Adults With Celiac Disease After Treatment With a Gluten-Free Diet
Alberto Rubio-Tapia, Mussarat W Rahim, Jacalyn A See, Brian D Lahr, Tsung-Teh Wu and Joseph A Murray
Abstract
OBJECTIVES:
Clinical response is typically observed in most adults with celiac disease (CD) after treatment with a gluten-free diet (GFD).
The rate of mucosal recovery is less certain.
The aims of this study were (1) to estimate the rate of mucosal recovery after GFD in a cohort of adults with CD, and (2) to assess the clinical implications of persistent mucosal damage after GFD.
METHODS:
The study group included adults with biopsy-proven CD evaluated at the Mayo Clinic who had duodenal biopsies at diagnosis and at least one follow-up intestinal biopsy to assess mucosal recovery after starting a GFD.
The primary outcomes of interest were mucosal recovery and all-cause mortality.
RESULTS:
Of 381 adults with biopsy-proven CD, 241 (73% women) had both a diagnostic and follow-up biopsy available for re-review.
Among these 241, the Kaplan–Meier rate of confirmed mucosal recovery at 2 years following diagnosis was 34% (95% confidence interval (CI): 27–40%), and at 5 years was 66% (95% CI: 58–74%).
Most patients (82%) had some clinical response to GFD, but it was not a reliable marker of mucosal recovery (P=0.7).
Serological response was associated with confirmed mucosal recovery (P=0.01).
Poor compliance to GFD (P<0.01), severe CD defined by diarrhea and weight loss (P<0.001), and total villous atrophy at diagnosis (P<0.001) were strongly associated with persistent mucosal damage.
There was a trend toward an association between achievement of mucosal recovery and a reduced rate of all-cause mortality (hazard ratio=0.13, 95% CI: 0.02–1.06, P=0.06), adjusted for gender and age.
CONCLUSIONS:
Mucosal recovery was absent in a substantial portion of adults with CD after treatment with a GFD.
There was a borderline significant association between confirmed mucosal recovery (vs. persistent damage) and reduced mortality independent of age and gender.
Systematic follow-up with intestinal biopsies may be advisable in patients diagnosed with CD as adults
2006 Apr;16(2):317-27.
Monitoring nonresponsive patients who have celiac disease.
Krauss N, Schuppan D.
Source
Department of Medicine I (Gastroenterology, Hepatology, Pneumonology and Endocrinology), University Hospital, Ulmenweg 18, Erlangen 91054, Germany. Norbert.Krauss@med1.imed.uni-erlangen.de
Abstract
....The major cause of failure to respond to a gluten-free diet is continuing ingestion of gluten, but other underlying diseases must be considered.
Many different drugs (eg, anti-tumor necrosis factor [TNF]-alpha) have been used in patients who have RCD ...{Refractory CD}
Steroid treatment has been reported to be effective even in patients who have underlying early EATL{Enteropathy-Associated T-cell Lymphoma}.
Histologic recovery in patients who have celiac disease usually takes several months but can take up to 1 year, even if the patient remains on a strict gluten-free diet.
Some patients report celiac-related symptoms for months after a single gluten intake.
The definitions for RCD in literature vary. The authors consider the definition give by Daum and colleagues ... suitable.
They defined true RCD as villous atrophy with crypt hyperplasia and increased IELs persisting for more than 12 months in spite of a strict gluten-free diet.
If a patient is not responding well to a gluten-free diet, three considerations are necessary: (1) the initial diagnosis of celiac disease must be reassessed;(2) the patient should be sent to a dietician to check for errors in diet or compliance problems, because problems with the gluten-free diet are the most important cause for persisting symptoms; (3) other reasons for persisting symptoms (eg, pancreatic insufficiency, irritable bowel syndrome, bacterial overgrowth, lymphocytic colitis, collagenous colitis, ulcerative jejunitis, protein-losing enteropathy,T-cell lymphoma, fructose intolerance, cavitating lymphadenopathy, and tropical sprue) should be considered.
Other causes for villous atrophy are Crohn's disease, collagenous sprue, and autoimmune enteropathy. Abdulkarim and colleagues ...examined 55 patients who had a diagnosis of nonresponsive celiac disease.
He found that 6 did not have celiac disease, and 25 still had some gluten ingestion.
Tursi and colleagues ... reported 15 patients who had celiac disease with persisting symptoms.
Because histology improved in all patients after several months, RCD was excluded. Of the 15 patients, 10 had small intestinal bacterial overgrowth, 2 showed lactose malabsorption causing the described symptoms, 1 had mistakenly taken an antibiotic containing gluten, and 1 patient each had Giardia lamblia and Ascaris lumbricoides. Thus, other entities must be considered in patients who have celiac disease and ongoing symptoms.....
*************
The American Journal of Gastroenterology ,
(9 February 2010) | doi:10.1038/ajg.2010.10
Mucosal Recovery and Mortality in Adults With Celiac Disease After Treatment With a Gluten-Free Diet
Alberto Rubio-Tapia, Mussarat W Rahim, Jacalyn A See, Brian D Lahr, Tsung-Teh Wu and Joseph A Murray
Abstract
OBJECTIVES:
Clinical response is typically observed in most adults with celiac disease (CD) after treatment with a gluten-free diet (GFD).
The rate of mucosal recovery is less certain.
The aims of this study were (1) to estimate the rate of mucosal recovery after GFD in a cohort of adults with CD, and (2) to assess the clinical implications of persistent mucosal damage after GFD.
METHODS:
The study group included adults with biopsy-proven CD evaluated at the Mayo Clinic who had duodenal biopsies at diagnosis and at least one follow-up intestinal biopsy to assess mucosal recovery after starting a GFD.
The primary outcomes of interest were mucosal recovery and all-cause mortality.
RESULTS:
Of 381 adults with biopsy-proven CD, 241 (73% women) had both a diagnostic and follow-up biopsy available for re-review.
Among these 241, the Kaplan–Meier rate of confirmed mucosal recovery at 2 years following diagnosis was 34% (95% confidence interval (CI): 27–40%), and at 5 years was 66% (95% CI: 58–74%).
Most patients (82%) had some clinical response to GFD, but it was not a reliable marker of mucosal recovery (P=0.7).
Serological response was associated with confirmed mucosal recovery (P=0.01).
Poor compliance to GFD (P<0.01), severe CD defined by diarrhea and weight loss (P<0.001), and total villous atrophy at diagnosis (P<0.001) were strongly associated with persistent mucosal damage.
There was a trend toward an association between achievement of mucosal recovery and a reduced rate of all-cause mortality (hazard ratio=0.13, 95% CI: 0.02–1.06, P=0.06), adjusted for gender and age.
CONCLUSIONS:
Mucosal recovery was absent in a substantial portion of adults with CD after treatment with a GFD.
There was a borderline significant association between confirmed mucosal recovery (vs. persistent damage) and reduced mortality independent of age and gender.
Systematic follow-up with intestinal biopsies may be advisable in patients diagnosed with CD as adults