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Celiac.com 11/09/2016 - Although exocrine pancreatic insufficiency (EPI) has been reported in a number of patients with celiac disease (celiac disease), it is not clear if this is primarily a functional or a structural defect. We studied pancreatic structural abnormalities by endoscopic ultrasound (EUS) in adult celiac disease patients with EPI. A team of researchers recently set out to prospectively assess pancreatic exocrine function in recently diagnosed celiac patients. The research team included Surinder S. Rana, Arvind Dambalkar, Puneet Chhabra, Ravi Sharma, Vishal Sharma, Satyavati Rana, Deepak K. Bhasin and Ritambhra Nada. They are variously affiliated with the Department of Gastroenterology, and the Department of Histopathology at the Post Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh, India. For their study, the team measured fecal elastase to prospectively assess pancreatic exocrine function in 36 recently diagnosed celiac patients. They relied on EPI by EUS and elastography to assess pancreatic structural changes in celiac patients. The team then reassessed exocrine functions in these patients after 3 months of gluten-free diet. Of the 36 celiac patients the team studied, 30 patients had anemia, 21 had diarrhea, and 7 had hypothyroidism. Ten patients had EPI with mean elastase levels of 141.6 μg/g of stool, only one of whom had a history of recurrent acute pancreatitis, while the other 9 patients had no history of either acute or chronic pancreatitis. Of these 10 patients, 8 (80%) had diarrhea, 8 (80%) anemia, and 2 (20%) had hypothyroidism. The team performed EUS in 8 patients. Five showed normal pancreas, 3 showed hyperechoic strands, and 2 patients showed hyperechoic foci without shadowing. None showed lobularity or parenchymal calcification. All patients, except the patient with recurrent pancreatitis, showed normal strain ratio. In 6 of the remaining 7 patients, follow-up fecal elastase fell within normal range. EPI, as measured by fecal elastase levels in adult celiac patients, possibly does not relate to structural alterations in the pancreatic parenchyma, and may be reversible by following a gluten-free diet. Source: Ann Gastroenterol. 2016 Jul-Sep;29(3):363-6. doi: 10.20524/aog.2016.0042. Epub 2016 May 11.

Celiac.com 04/20/2016 - People with celiac disease very often have reflux symptoms. A team of researchers recently set out to evaluate mucosal integrity and motility of the lower esophagus as possible contributors to reflux symptoms in patients with celiac disease. The research team included María Inés Pinto-Sánchez, Fabio D. Nachman, Claudia Fuxman, Guido Iantorno, Hui Jer Hwang, Andrés Ditaranto, Florencia Costa, Gabriela Longarini, Xuan Yu Wang, Xianxi Huang, Horacio Vázquez, María L. Moreno, Sonia Niveloni, Premysl Bercik, Edgardo Smecuol, Roberto Mazure, Claudio Bilder, Eduardo C. Mauriño, Elena F. Verdu, and Julio C. Bai. They are variously affiliated with the Farncombe Family Digestive Health Research Institute at McMaster University, in Hamilton, Ontario, Canada, the Department of Medicine, "Dr. Carlos Bonorino Udaondo" Gastroenterology Hospital in Buenos Aires, Argentina, Favaloro University Hospital in Buenos Aires, Argentina, Consejo de Investigación en Salud, MSAL, Gobierno de la Ciudad Autónoma de Buenos Aires, Argentina, and with the Gastroenterology Chair, Universidad del Salvador in Buenos Aires, Argentina. For their study, they enrolled newly diagnosed celiac disease patients with and without reflux symptoms, non-celiac patients with classical reflux disease (GERD), and control subjects, who had no reflux symptoms. Using both light microscopy and electron microscopy, they assessed endoscopic biopsies from the distal esophagus for dilated intercellular space (DIS). They used qRT-PC to determine tight junction (TJ) mRNA proteins expression for zonula occludens-1 (ZO-1) and claudin-2 and claudin-3 (CLDN-2; CLDN-3). Overall, patients with active celiac disease showed higher DIS scores than controls, and similar to GERD patients. They found altered DIS even in celiac disease patients without reflux symptoms, who had normalized after one year of a gluten-free diet. Celiac disease patients with and without reflux symptoms had lower expression of ZO-1 than controls. Celiac disease and GERD patients showed similar expression of CLDN-2 and CLDN-3. This study shows that patients with active celiac disease have altered esophageal mucosal integrity, independent of any reflux symptoms. Loss of TJ integrity in the esophageal mucosa may result from altered expression of ZO-1, which may contribute to the development of reflux symptoms. Source: Canadian Journal of Gastroenterology and Hepatology. Volume 2016 (2016), Article ID 1980686, 9 pages

Celiac.com 09/16/2013 - Until recently, researchers thought celiac disease was mainly a problem in Northern Europe and Australasia, and uncommon in North America and the Middle East. However, with better data, researchers now regard celiac disease to be equally common in all these places. Celiac disease is still generally seen as rare in Asia and Sub-Saharan Africa, but a team of researchers wanted to get a better idea of geographical differences and time trends in the frequency of celiac disease. The research team included J. Y. Kang, A. H. Y. Kang, A. Green, K. A. Gwee, and K.Y. Ho. They are affiliated with the Department of Gastroenterology, St George's Hospital, London, UK, the Yong Loo Lin School of Medicine at the National University of Singapore, and with the Department of Gastroenterology and Hepatology at the National University Health System in Singapore. To get the data that would help them to compare geographical differences and time trends, the team conducted Medline and Embase searches covering a period from 1946 to 1980, using the key words: coeliac disease or celiac disease + prevalence, incidence or frequency. Their data showed significant differences between and within countries in the prevalence and incidence of celiac disease. For example, in all of reported English medical literature, there have been only 24 ethnic Chinese and Japanese patients with celiac disease. Of celiac-associated HLA DQ antigens, DQ2 occurs in 5–10% of Chinese and sub-Saharan Africans, compared to 5–20% in Western Europe. DQ8 occurs in 5–10% of English, Tunisians and Iranians, but in less than 5% of Eastern Europeans, Americans and Asians. Rates and overall numbers of both clinically and serologically diagnosed celiac disease have risen in recent years. Celiac disease is increasing in frequency, with significant geographical differences. The team's geographical and temporal differences seem genuine, but a large number of hypothesis and lack of diagnostic facilities have made it difficult to reach any solid conclusions. Although few cases have been found in Asia and Sub-Saharan Africa, there is a significant prevalence of HLA DQ2 and wheat consumption is about the same as in Western Europe. It is possible that celiac disease may become more common in these countries in the future. Source: Aliment Pharmacol Ther. 2013;38(3):226-245.

Celiac.com 11/18/2009 - Clinical studies of adults with celiac disease have shown that duodenal mucosal histopathological changes may be patchy, and the diagnostic value of duodenal bulb biopsies is thought to be limited. Very little data exist regarding how this applies to children with celiac disease. A team of researchers recently set out to assess the prevalence of variable biopsy findings and duodenal bulb involvement in children with celiac disease, as well as its association with clinical parameters. The research team was made up of Dascha C. Weir MD, Jonathan N. Glickman MD, Tracey Roiff, Clarissa Valim MD, ScD, and Alan M. Leichtner MD. The team analyzed the prevalence of variable biopsy findings and duodenal bulb involvement in children with celiac disease, together with its association with clinical parameters. They looked at a total of 198 consecutive cases of celiac disease diagnosed at the Children’ s Hospital from 2001 to 2005. The team scored all biopsies using the Marsh criteria applied by a pathologist blinded to the clinical data. The researchers categorized mucosal changes as 'focal' if changes consistent with celiac disease and normal mucosa were found within a single biopsy fragment. They defined 'patchiness' as variation of at least one Marsh grade between separate fragments in a biopsy set. The median patient age was 9.3 years; 62% were female. The researchers took more than 700 biopsy samples, an average of 3.6 per patient. In 101 cases, they took biopsy sample from both the duodenal bulb and the second portion of the duodenum. They classified 36 biopsy samples (18%) as focal. They classified 105 samples (53%) as 'patchy', with at least 1 normal biopsy fragment was present in 71 cases (36 %). In 10 cases, researchers made reliable diagnosis only via bulb biopsy. There was no association with the clinical features examined. The research team concluded that duodenal involvement in childhood celiac disease is often patchy and may show variable severity even within a single biopsy fragment not reliably predicted by clinical characteristics. To maximize diagnostic yield, they recommend taking multiple endoscopic biopsies, including the duodenal bulb, in suspected cases of pediatric celiac disease. Source: Am J Gastroenterol 6 October 2009; doi: 10.1038/ajg.2009.557

This update comes to us from Frederik Willem Janssen, The Netherlands: fwjanssen@WXS.NL About a week ago I promised to post info about agenda item 4 (Gluten Free Food) as dealt with at the meeting of Codex Alimentarius NFSDU (Nutrition and Food for Special Dietary Uses) which was held in September in Berlin Germany. As usual this meeting starts on Monday and continues till Wednesday, Thursday is a day off (time for the secretariat to draw resolutions) and on Friday these draft resolutions are discussed. Unfortunately I wasnt able to stay till Friday. However, the resolutions as discussed on Friday were handed to me afterwards however and I pass them with some corrective changes accepted during that day. For those of you who have no interest in reading this clerical stuff I summarize: The proposed limits (20) for food gluten-free by nature and 200 for food "rendered gluten-free" will stay between square brackets (so no decision has been made). The same holds for oats, awaiting further toxicological data about its celiac-toxicity it should be considered as toxic. The main obstacle for finalizing the standard is the lack of an appropriate method of analysis. Progress has been made but still not to that extent that enforcing agencies can be satisfied. Maybe we will see some progress in the next 2 years! Proposed Revisions: Alinorm 99/26, Draft Revised Standards for Gluten-Free Foods (Agenda Item 4): 31. The Committee recalled that the Twenty-second Session of the CAC adopted the Proposed Draft Standard for Gluten-Free Foods at Step 5 while recommending that comments on methods of analysis and on amounts of gluten in gluten free foods should be taken into account when finalizing the standard. The Committee noted that without an appropriate method of analysis it was not scientifically justified to advance the Draft further. 32. The Delegation of Sweden introduced their recent study on gluten determination in foods by an enzyme immunoassay using a monoclonal antibody against omega-gliadin (CRD 33), noting that the detection limit of the method (ref. AOAC 991.19) was about 20 - 40 ppm and the repeatability was acceptable. Some Delegations pointed out that the method presented raised some technical concerns: it was performed only on wheat and due to this, uncertainty exists as regards its applicability to other cereals. There were also concerns about the reproducibility of the method. It measured only omega-gliadin and other gliadins should also be taken into account. The need of further improvement was raised. Spain expressed concern about setting units where no method of analysis is available and not all the different types of gliadins can be detected. 33. The Committee noted that in some cases a proprietary method was the most specific way to detect an analyte, such as in the case of gluten detection. Since Codex had not endorsed these techniques as methods of analysis of Codex, the CCMAS (Codex committee on Methods of Analysis and Sampling) should consider this problem. 34. Several delegations suggested that the Committee should ask FAO and WHO to convene an Expert Consultation to address the issue of the level and the method of analysis. Other delegations proposed to consult the CCMAS on this issue. The Secretariat informed the Committee that on the request of the CCFL (Codex committee on Food Labeling), JECFA (Joint expert committee on Food Additives) was prepared to consider the question of hypersensitivity at its 53rd Session (June 1999) and the intolerance to gluten might be discussed in this context. The Secretariat recalled that the role of the CCMAS was to endorse methods of analysis proposed by specialized Committees and the CCNFSDU needed to specify the method. 35. Several delegations and the Observer from the AAC (Association des Amidonneries Cooperative) proposed that the discussion of this draft should be adjourned until a reliable method of analysis became available. Other delegations were in favor of continuing work on it in order to meet the urgent need of the patients suffering from coeliac disease and proposed to advance the proposed draft for a single level of 200 ppm to step 8. Taking into account the absence of an appropriate and accurate method of analysis, it was proposed to maintain the gluten free level at 200 ppm for all foods and to include a new preamble suggesting the a revision of the standard when a method of analysis or new scientific evidence became available. 36. While concerning the proposed definition of "gluten-free" foods, several delegations wanted to point out that the current approach was confusing and misleading the consumer and that the level should be uniform for all foods. However, other delegations and the Observer from AOECS stressed the need for two levels with regard to the naturally gluten free foods and the products which had been rendered gluten free. The Committee noted that the proposed term "gluten-free" might mislead the consumer and recognized that the term "low or reduced in gluten" should be considered. 37. The Observer from AOECS, supported by some delegations, expressed the view that the level of 200 ppm for all gluten-free foods was too high to protect coeliacs and the gluten level should refer only to the end product for better consumer protection. 38. The Delegation of Finland proposed to remove the oats from the list as scientific studies showed that oats can be tolerated by celiacs and allows to provide dietary fibers for coeliacs. The Observer from AOECS, supported by some delegations, stressed that the square brackets on oats should be removed as oats might have negative impact on the health of coeliacs and that the medical experts had not reached consensus on this issue. 39. The Committee recognized that the development of reliable method of analysis of gluten was the key point of this discussion and that the development of the method should be encouraged by all means. Status of the Draft Revised Standard for Gluten-Free Foods 40. The Committee agreed to leave the text of the draft as it was in CX/NFSDU 98/4 and to return it to Step 6 for further consideration. The Committee also agreed that the question regarding the proprietary techniques should be raised to the CCMAS as a general matter. The following documents were discussed during the meeting: CX/NFSDU 98/4 - Add 1 (Comments from Australia, Spain, UK, AAC, ISDI); CX/NFSDU 98/4 - Add 2 (AOECS); CRD 3 (Uruguay, ISDI); CRD 13 (USA); CRD 21 (Spain); CRD 33 = CRD 42 (Sweden); CRD 44 (India); CRD 51 (Norway).

This 11/29/98 update comes to us from Frederik Willem Janssen, The Netherlands: fwjanssen@WXS.NL About a week ago I promised to post info about agenda item 4 (Gluten Free Food) as dealt with at the meeting of Codex Alimentarius NFSDU (Nutrition and Food for Special Dietary Uses) which was held in September in Berlin Germany. As usual this meeting starts on Monday and continues till Wednesday, Thursday is a day off (time for the secretariat to draw resolutions) and on Friday these draft resolutions are discussed. Unfortunately I wasnt able to stay till Friday. However, the resolutions as discussed on Friday were handed to me afterwards however and I pass them with some corrective changes accepted during that day. For those of you who have no interest in reading this clerical stuff I summarize: The proposed limits (20) for food gluten-free by nature and 200 for food rendered gluten-free will stay between square brackets (so no decision has been made). The same holds for oats, awaiting further toxicological data about its celiac-toxicity it should be considered as toxic. The main obstacle for finalizing the standard is the lack of an appropriate method of analysis. Progress has been made but still not to that extent that enforcing agencies can be satisfied. Maybe we will see some progress in the next 2 years! Proposed Revisions: Alinorm 99/26, Draft Revised Standards for Gluten-Free Foods (Agenda Item 4): 31. The Committee recalled that the Twenty-second Session of the CAC adopted the Proposed Draft Standard for Gluten-Free Foods at Step 5 while recommending that comments on methods of analysis and on amounts of gluten in gluten free foods should be taken into account when finalizing the standard. The Committee noted that without an appropriate method of analysis it was not scientifically justified to advance the Draft further. 32. The Delegation of Sweden introduced their recent study on gluten determination in foods by an enzyme immunoassay using a monoclonal antibody against omega-gliadin (CRD 33), noting that the detection limit of the method (ref. AOAC 991.19) was about 20 - 40 ppm and the repeatability was acceptable. Some Delegations pointed out that the method presented raised some technical concerns: it was performed only on wheat and due to this, uncertainty exists as regards its applicability to other cereals. There were also concerns about the reproducibility of the method. It measured only omega-gliadin and other gliadins should also be taken into account. The need of further improvement was raised. Spain expressed concern about setting units where no method of analysis is available and not all the different types of gliadins can be detected. 33. The Committee noted that in some cases a proprietary method was the most specific way to detect an analyte, such as in the case of gluten detection. Since Codex had not endorsed these techniques as methods of analysis of Codex, the CCMAS (Codex committee on Methods of Analysis and Sampling) should consider this problem. 34. Several delegations suggested that the Committee should ask FAO and WHO to convene an Expert Consultation to address the issue of the level and the method of analysis. Other delegations proposed to consult the CCMAS on this issue. The Secretariat informed the Committee that on the request of the CCFL (Codex committee on Food Labeling), JECFA (Joint expert committee on Food Additives) was prepared to consider the question of hypersensitivity at its 53rd Session (June 1999) and the intolerance to gluten might be discussed in this context. The Secretariat recalled that the role of the CCMAS was to endorse methods of analysis proposed by specialized Committees and the CCNFSDU needed to specify the method. 35. Several delegations and the Observer from the AAC (Association des Amidonneries Cooperative) proposed that the discussion of this draft should be adjourned until a reliable method of analysis became available. Other delegations were in favor of continuing work on it in order to meet the urgent need of the patients suffering from coeliac disease and proposed to advance the proposed draft for a single level of 200 ppm to step 8. Taking into account the absence of an appropriate and accurate method of analysis, it was proposed to maintain the gluten free level at 200 ppm for all foods and to include a new preamble suggesting the a revision of the standard when a method of analysis or new scientific evidence became available. 36. While concerning the proposed definition of gluten-free foods, several delegations wanted to point out that the current approach was confusing and misleading the consumer and that the level should be uniform for all foods. However, other delegations and the Observer from AOECS stressed the need for two levels with regard to the naturally gluten free foods and the products which had been rendered gluten free. The Committee noted that the proposed term gluten-free might mislead the consumer and recognized that the term low or reduced in gluten should be considered. 37. The Observer from AOECS, supported by some delegations, expressed the view that the level of 200 ppm for all gluten-free foods was too high to protect coeliacs and the gluten level should refer only to the end product for better consumer protection. 38. The Delegation of Finland proposed to remove the oats from the list as scientific studies showed that oats can be tolerated by celiacs and allows to provide dietary fibers for coeliacs. The Observer from AOECS, supported by some delegations, stressed that the square brackets on oats should be removed as oats might have negative impact on the health of coeliacs and that the medical experts had not reached consensus on this issue. 39. The Committee recognized that the development of reliable method of analysis of gluten was the key point of this discussion and that the development of the method should be encouraged by all means. Status of the Draft Revised Standard for Gluten-Free Foods 40. The Committee agreed to leave the text of the draft as it was in CX/NFSDU 98/4 and to return it to Step 6 for further consideration. The Committee also agreed that the question regarding the proprietary techniques should be raised to the CCMAS as a general matter. The following documents were discussed during the meeting: CX/NFSDU 98/4 - Add 1 (Comments from Australia, Spain, UK, AAC, ISDI); CX/NFSDU 98/4 - Add 2 (AOECS); CRD 3 (Uruguay, ISDI); CRD 13 (USA); CRD 21 (Spain); CRD 33 = CRD 42 (Sweden); CRD 44 (India); CRD 51 (Norway).