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Modern diagnosis of
celiac disease
Jernej Dolinšek, MD, PhD
Department of Paediatrics
University Medical Centre Maribor, Slovenia
Σάββατο, 20 Ιουνίου 2009
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history of celiac disease
immunopathogenesis
clinical picture
diagnostic criteria serology
histopathology
new methods genetics
Immunohistochemistry
serology
future perspectives
Overview
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1888 SJ Gee: Description of CD: On coeliac affection
1950 WK Dicke: Toxic effect of wheat
1959 M Shiner: Oral biopsy of intestinal mucosa
1969 ESPGHAN: Classic criteria
1989 ESPGHAN: Revised criteria
2005 NASPGHAN criteria
possible new revisions
Background
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Cooke WT and Holmes GKT: Coeliac disease, 1984
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Celiac disease and immunology
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enamel defects
DH
celiac
disease
epilepsy and cerebral
calcifications
autoimmun
e diseases
liver disease
lymphoma
osteopenia
ataxia
DR3, DQ2 DR4, DQ8
GLUTEN
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Diagnosis of CD
history
physical examination
serology
intestinal biopsy
histology
immunohistochemistry
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Diagnosis of CD
If you suspect it - you will detect it.
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Korponay Szabo I. Heim Pál Children’s Hospital, Budapest, Hungary
CD 020406080
100120140160180200220
1982 1987 1992 1997 20020
500
1000
1500
2000
2500
3000
3500
New CD/year Number of EMA tests
EMA
Serologic markers
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Current golden standard
intestinal biopsy
tissue diagnosis of CD
Diagnostic criteria
“classic criteria” ESPGHAN
3 biopsies
“revised criteria” ESPGHAN
1 biopsy
serological markers
- AGA, EMA, t-TG
Weijers HA, et al. Diagnostic criteria in coeliac disease. Acta Paediatr Scand 1970.
Walker Smith JA, et al. Revised criteria for diagnosis of coeliac disease. Arch Dis Child 1990.
Diagnosis of CD
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Classic criteria ESPGHAN
intestinal biopsy – GOLDEN STANDARD
life-long gluten intolerance
abnormal mucosa when eating gluten
normal mucosa after GFD
deterioration after gluten reintroduction
gluten challenge
3 biopsies
Weijers et al. Acta Paediatr Scand 1970;59:461-3.
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Diagnostic tools
histology
aspiration capsule biopsy
endoscopic biopsy
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Diagnostic tools
histology
aspiration capsule biopsy
endoscopic biopsy
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Intestinal biopsy
Histologic changes
mucosal atrophy
Marsh classification
type 0: preinfiltrative phase
type 1: infiltrative phase
type 2: infiltrative-hyperplastic phase
type 3 (a, b, c): destructive phase
type 4: atrophic-hypoplastc phase
villous atrophy, crypt hyperplasia, IEL count
Marsh MN. Gluten, major histocompatibility complex, and the small intestine. A molecular and immunobiologic approach to the s pectrum of gluten
sensitivity ('celiac sprue'). Gastroenterology 1992.
Oberhuber G, et al. The histopathology of coeliac disease: time for a standardised report scheme for pathologist. Eur J Gastroenterol Hepatol 1999.
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BIOPSY I
typical changes normal mucosa
BIOPSY II
GFD
normal life
normal mucosa typical changes
challenge
relapse after 3-6 months
BIOPSY III
normal mucosatypical changes
CELIAC BIOPSY IV
CELIAC FOLLOW UP
normal mucosatypical changes
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Revised criteria ESPGHAN
intestinal biopsy – GOLDEN STANDARD
abnormal mucosa when eating gluten
clinical improvement after GFD
normalisation of serologic markers
challenge no longer needed
1 biopsy
exceptions
uncertain initial diagnosis
children under age of 2
Walker Smith et al. Arch Dis Child 1990; 65: 909-11.
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Serologic markers
Serologic markers
AGA IgA and IgG
ELISA, commercial kits
EMA IgA
indirect immunofluorescence, commercial kits
substrate: monkey esophagus (umbillical cord)
t-TG IgA (IgG)
ELISA, commercial kits
substrate: human recombinant t-TG
deamidated gliadin IgA, IgG
ELISA, commercial kits
other Ab (ARA, JAB, antiglutenin)
importance of total IgA determination
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IgA reticulin antibodies (ARA)
IgA endomysial antibodies (EMA)
Children Patients Controls Sensitivity Specificity Sensitivity Specificity%
Bottaro 1997 50 25 74 100 96 96Hällström 1989 14 24 100 100 100 100Kolho 1997 53 114 96 92 94 100Lerner 1994 34 41 65 100 97 98Mäki 1984 29 245 97 98Sacchetti 1996 32 42 94 100 97 100Volta 1991 29 20 52 100 90 100
Adults
Ferreira 1992 21 160 90 99 100 99Hällström 1989 35 145 91 100 91 100Mäki 1991 13 109 92 95 92 95Sategna-Guidetti 1997 104 94 95 100Valdimarsson 1996 19 125 74 100Volta 1991 41 20 44 100 85 100
IgA gliadin antibodies
IgG gliadin antibodies
Children Patients Controls Sensitivity Specificity Sensitivity Specificit%
Asher 1990 36 92 97 92Bottaro 1997 50 25 92 68 50 36Lerner 1994 34 41 52 94 88 92Stahlberg 1986 31 278 90 86 94 67
Adults
Bodé 1994 13 87 46 98 62 97Ferreira 1992 21 160 90 85 76 88Kilander 1983 36 54 67 94 78 94Maki 1991 13 109 31 87 46 89McMillan 1991 28 68 100 100 57 87Sategna-Guidetti 1995 100 109 55 100 78 82
Vogelsang 1995 49 53 82 83 73 74
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Serologic markers - EMA
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0.1
1
10
100
1000
10000
IgG
an
ti-t
TG
(U
/ml)
Dermatitisherpetiformis
Coeliacdisease
Controls
(n=134) (n=170)(n=131)
0.1
1
10
100
1000
10000
100000
IgA
an
ti-t
TG
(U
/ml)
A B
Dermatitisherpetiformis
Coeliacdisease
Controls
(n=134) (n=170)(n=131)
Serologic markers – t-TG
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Untreated On diet for 6 months
Serologic markers – t-TG
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CLINICAL PICTURE
CELIAC
yearly follow up (clinical picture, serology)
no change improvement
diet?other dg?
BIOPSY
typical clinical picture
GFD
clinical picture and serology
mucosal atrophy
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Other (newer) methods
genetic testing
histology
serology
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CD and genetics
Celiac disease: OMIM 142800
Medline: cca. 1600 hits
celiac disease and genetics
DP DQ DR B C A
II III Iclass
Short
arm
Chromosome 6
DQ2 DR3 B8 A1DR7
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Genetic predisposition for CD
twin analysis
family occurence – 10%
poligenic disease
most important factor HLA locus
chromosome 6p21.3
~90% patients HLA-DQ2
~10% patients HLA-DQ8
Karell K, et al. HLA types in celiac disease patients not carrying the DQA1*05-DQB1*02 (DQ2) heterodimer: results from the European Genetics Cluster on
Celiac Disease. Hum Immunol 2003.
Sollid LM, Lie BA. Celiac disease genetics: current concepts and practical applications. Clin Gastroenterol Hepatol 2005.
CD and genetics
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Genetic predisposition for CD
HLA locus (chromosome 6p21.3)
HLA-DQ2 or HLA-DQ8
Sollid LM, Lie BA. Celiac disease genetics: current concepts and practical applications. Clin Gastroenterol Hepatol 2005 .
CD and genetics
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HLA-DQ2, DQ4
HLA-DQ2, DQ5
Genetic testing
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Genetic testing
HLA-DQ8, DQ8
HLA-DQ5, DQ7
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Histology
mucosal atrophy
Histology
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IEL subpopulations
CD3
alpha/beta IEL
gamma/delta IEL
Enterocyte apoptosis
TUNEL-terminal uridine nick end labeling
IgA t-TG Ab tissue deposits
Histology
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Histology
IEL count
immunohistochemical methods
Histology
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Histology
IEL count
immunohistochemical methods
Histology
Kaukinen et al. Dig Dis Sci 2001;46:879
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Histology
IEL count
Histology
Kaukinen et al. Scand. J Gastroenterol, 1998
0
10
20
30
40
50
Non-
coeliac
control
subjects
Untreated
coeliac disease
Coeliac disease
excluded on biopsy
60
gd+
T-c
ell
s/m
m
>60
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• IEL subpopulations
– CD3
– alpha/beta IEL
– gamma/delta IEL
• Enterocyte apoptosis
– TUNEL-terminal uridine nick end labeling
• IgA t-TG Ab tissue deposits
Histology
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• IEL subpopulations
– CD3
– alpha/beta IEL
– gamma/delta IEL
• Enterocyte apoptosis
– TUNEL-terminal uridine nick end labeling
• IgA t-TG Ab tissue deposits
Histology
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Normal Early phase Celiac flat lesion
IgA / Transglutaminase 2
Histology
Korponay-Szabo I, et al. Gut, 2004
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Sens
%
Specif
%
Mucosal IgA-
deposits
93 93
Serum
autoantibodies
76 83
Mucosal villous tip
IELs
88 71
Mucosal gd IELs 76 60
Mucosal IELs
(Marsh 1)
59 57
HLA DQ2 or DQ8 100 66
Salmi et al., Aliment Pharmacol Ther, 2006
Other (newer) methods
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New diagnostic tests
serological tests
tissue transglutaminase Ab (t-TG)
reliable, relatively inexpensive test
rapid finger-prick t-TG test
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Anti-IgA antibody
(Control line)
New diagnostic tests
+
-
!
!
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serological tests
deamidated gliadin Ab (IgG, IgA)
high corellation with EMA and t-TG
glutenin Ab
new microsystems
simultaneus
multiple Ab test
IgA determination
HLA-DQ2/DQ8 status
Prince HE. Evaluation of the INOVA diagnostics enzyme-linked immunosorbent assay kits for measuring serum immunoglobulin G (IgG) and IgA
to deamidated gliadin peptides. Clin Vaccine Imunol 2006.
Aleanzi M, et al. Celiac disease: antibody recognition against native and selectively deamidated gliadin peptides. Clin Chem. 2001
New diagnostic tests
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Conclusion
ESPGHAN criteria
classic (at least 3 biopsies)
revised (1 biopsy)
future revisions (ESPGHAN working group)
NASPGHAN criteria
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Conclusion
clinical picture
typical celiac disease
atypical celiac disease
children
adults
diagnostic tools
serological tests
EMA, t-TG, (watch for total IgA)
genetic tests
HLA DQ2/DQ8
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Conclusion
diagnostic tools
histology
clinical picture after introduction of GFD
reversibility of changes
clinical picture
serological tests
histological changes
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Conclusion
novel tests
serological tests
rapid t-TG test
other potentialy useful tests
deamidated gliadin
glutenin
histological tests
IEL
IgA t-TG deposits
apoptosis
nanotechnology
rapid multiparameter testing
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Σας ευχαριστώ πολύ