Small bowel diseases. Györgyi Műzes 2015/16-I. Semmelweis University, 2nd Dept. of Medicine

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1 Small bowel diseases Györgyi Műzes 2015/16-I. Semmelweis University, 2nd Dept. of Medicine

2 Celiac disease (revised definition!) a systemic autoimmune disorder Occurs in genetically susceptible individuals DQ2 and/or DQ8 positive HLA haplotype is necessary but not sufficient A unique autoimmune disorder since: both the environmental trigger (gluten) and the autoantigen (tissue transglutaminase) are welldefined elimination of the environmental trigger leads to an almost complete resolution of the disease

3 MHC II genes *only 5 % of individulas with HLA-DQ2 and 0.5 % of those with HLA-DQ8 have celiac disease *HLA-DQ2/DQ8: in 99 % of all patients with celiac disease (Caucasian population: %) *familial clustering: concordance rate for MZ twins: %! *HLA-DQ2 /DQ8: % of the genetic risk

4 Non-MHC genes IL12, CCR1-3

5 Non-dietary environmental factors Infections Viral sequence-homology between -gliadin and adenovirus type 12 & 7, rubella, human herpesvirus type 1, rotavirus Parasitic sequence-homology between -gliadin and plasmodium yoelli

6 Dietary gluten peptides (prolamines) Ser-containing group of ~ (PSQQ or QQQP motifs of α-gliadin or 44-55) : toxic Tyr-containing group of ~ (QQPY or QPYP motifs of α-gliadin 57-68, or 57-89): immunogenic Toxic peptides induce: TJ dysfunction, apoptosis, altered cell differentiation --- impairment of the epithelial barrier, increased permeability Immunogenic peptides induce: adaptive immune response, CD4+T-cell stimulation (via binding to HLA-DQ2 or-dq8 on APCs

8 TCRαβCD % TCRαβCD % TCRγδCD % HLA-E hsp: MICA/B

12 Celiac Disease Three peaks regarding its manifestation: infancy 2nd to 3rd decade of life 5th to 6th decade of life average delay in diagnosis cca. 7 years!!!

13 Celiac disease: symptoms - often presents later, between the ages of 10 and 40 yrs - the impressive clinical picture of a child with life-threatening malabsorption is often replaced by the mostly atypical presentation of adult celiac disease Gastrointestinal manifestations - diarrhea with bulky, foul-smelling, floating stools due to steatorrhea and flatulence - consequences of malabsorption (growth failure in children, weight loss, severe anemia, neurologic disorders due to deficiencies of B vitamins, and osteopenia from deficiency of vitamin D and calcium)

14 Celiac disease: symptoms Subclinical disease - most patients have mild and unspecific symptoms - fatigue, borderline iron deficiency, otherwise unexplained elevations in serum aminotransferases - no symptoms at all - significant nutritional deficiencies - recurrent abdominal pain - mood changes

15 Symptom Percent Iron deficiency With anemia 29 Without anemia 27 Recurrent abdominal pain 24 Mood changes 17 Recurrent aphthous stomatitis 11 Poor appetite 10 Recurrent diarrhea 9 Short stature 7 Abdominal distention 5 Constipation 2 Pubertal delay 2 Hypoalbuminemia 2

16 Infertility Rheumatic disorders Vitamin D and calcium deficiency Osteomalacia Osteoporosis Neurologic disorders: Kidney disease Glomerular IgA deposition Hyposplenism pathogenesis unknown Prophylactic pneumococcal vaccination has been suggested Idiopathic pulmonary hemosiderosis Depression Epilepsy Migraine headaches Anxiety - Suicidal tendency Carpal tunnel syndrome Myopathy

18 Remodeling

19 Remodeling

20 Serological tests Anti-gliadin antibodies (AGA) Anti-endomysial antibodies (EMA) Anti-tissue transglutaminase antibodies (ttg) 1st generation (guinea pig recombinant 2nd generation (human recombinant) HLA typing

21 Celiac disease-associated conditions -Dermatitis herpetiformis -Diabetes mellitus type I. -Thyroid diseases -Selective IgA deficiency -Gastroesophageal reflux -Eosinophilic esophagitis -Inflammatory bowel disease -Pancreatitis -Liver diseases -Down syndrome -Menstrual and reproductive issues -Myocarditis and cardiomyopathy; Ischemic heart disease

23 Prevalence of systemic autoimmune diseases in celiac disease average population celiac disease (%) Sjögren s syndr rheumatoid arthritis PM/DM SLE scleroderma MCTD Systemic vasculitides PBC ulcerative colitis

24 Prevalence of celiac disease in autoimmune diseases Sjögren s syndr RA 5.0 PM/DM 1.2 SLE 1.0 (%) PBC 2.6 ulcerative colitis 23.3 T1D 8.0 AITD 6.0

25 Treatment of Celiac Disease Gluten-free diet (GFD: life long!) compliance problems variations in food labeling possible cross-contamination of other foodstuffs by gluten are quite common!

26 Causes of poor response to gluten-free diet Wrong diagnosis Gluten ingestion* Lactose intolerance* Pancreatic insufficiency* Microscopic colitis* Bacterial overgrowth* Other food intolerances (fructose, milk, soy) Collagenous colitis IBD Collagenous sprue Ulcerative jejunitis Autoimmune enteropathy Adenocarcinoma EATL Refractory sprue (+/- clonal T cell populations

27 Risk of cancer in celiac disease Definite Increased Non-Hodgkin's lymphoma T>B (EATL!) Small bowel adenocarcinoma Decreased Breast Lung? Possible Esophagus Melanoma Large bowel Liver Oropharyngeal Pancreas Mortality rate: appr x higher!

Coeliac Disease: Diagnosis and clinical features

Coeliac Disease: Diagnosis and clinical features Australasian Gastrointestinal Pathology Society AGM 28 Oct 2016 Dr. Hooi Ee Gastroenterologist, Sir Charles Gairdner Hospital Coeliac disease Greek: koiliakos