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  • Jonas F. Ludvigsson, M.D.
    Being Pregnant with Celiac Disease: What does it Mean to the Fetus?
    Image Caption: Image: CC--Mysudbury.ca Ouisudbury
    Celiac.com 09/01/2018 - Celiac disease is a common disease triggered by gliadin exposure in genetically sensitive individuals.  It has long been known that untreated celiac disease is associated with intestinal malabsorption, but it is also associated with ongoing inflammation.  This inflammation may have adverse effects on the uptake of important nutrients.  This is probably the underlying reason for the increased risk of osteoporosis demonstrated in patients with celiac disease.  Malabsorption and ongoing inflammation in untreated celiac disease could also potentially have a negative effect on fetal development.
    Several reports have indicated an adverse effect of untreated celiac disease on pregnancy outcome.  We set out to use the national registers of Sweden to:
    Evaluate the association of untreated celiac disease and birth weight, pregnancy duration and intrauterine growth. Evaluate the same association in treated celiac disease. Compare the risk of the above two groups with a reference group of 2.8 million births to mothers who never had a diagnosis of celiac disease. A fourth objective was to evaluate placental weight to see if lower placental weight was more frequent in women with celiac disease. We found that untreated celiac disease (women diagnosed after pregnancy, but most likely having untreated celiac disease at time of pregnancy) was associated with a two-fold risk of low birth weight, pre-term birth, intrauterine growth retardation and cesarean section.
    The low birth weight and intrauterine growth retardation may have been mediated through malabsorption, since placental weight was lowest in women with untreated celiac disease.
    This study was published in Gastroenterology Aug 2005. A link to this paper can be found here: gastrojournal.org
    After that we set out to evaluate the association between adverse pregnancy outcome in males with untreated and treated celiac disease.  In a previous paper, we had found an increased risk of adverse pregnancy outcome when the father had celiac disease (Ludvigsson et al, Gut, 2001).  Now, taking advantage of the large Swedish national registers (all births since 1973 and onwards are recorded), we found no increased risk of low birth weight, pre-term birth or cesarean section in infants to fathers with untreated or treated celiac disease.  This study was published in the Scandinavian Journal of Gastroenterology in Feb 2006.

    Celiac.com Sponsor: Banner
    Meet Thrive Market, Your New Destination for Celiac-Friendly Groceries
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    Celiac.com 09/01/2018 - Finding the best celiac-friendly products can be a challenge, but the hunt is about to get a whole lot easier thanks to a healthy food company that’s changing the way we shop for groceries. 
    Thrive Market’s mission is simple: make healthy living and organic food accessible to everyone—regardless of where they live or how much they make. How do they do it? By offering organic, wholesome foods (including celiac and gluten-free options) and nontoxic home and body care products for less than what you’ll find in traditional retail stores—all delivered straight to your door. Here are just a few of the perks you can enjoy when you join:
    Everyday low prices: Shop trusted celiac-friendly brands like Simple Mills, Enjoy Life, Purely Elizabeth, The New Primal, Lundberg Farms, Country Life, Amy’s, Banza, Sir Kensington’s, and many more, at 25-50% off!  Find exactly what you need: Thrive Market has done the work for you! It carries the top allergen-friendly and specialty brands, and the site and free app make it simple to find exactly what you need. Easily filter categories and dietary needs, like “gluten-free,” “certified gluten-free,” and “certified organic.”   Shipped to your door: Skip lines at the grocery store, shop in the comfort of your home, and get everything delivered to your door. Eco-friendly packaging: All boxes and inserts are made from recycled paper and are recyclable. Thrive Market is 100% carbon-neutral and certified through carbonfund.org. Our certification covers national shipping, packaging materials, warehouse utilities, even the commutes of our team. Shop with a cause: Thrive Market believes by working together, it can make healthy food accessible for all. That’s why it started Thrive Gives, a program that provides grocery stipends, educational content, and free memberships to teachers, veterans, and low-income families. Its efforts are made possible by a dedicated team, partners, and committed Thrive Market members. For every paid Thrive Market member, we donate a free membership to a family in need!   So, what are you waiting for? Get an extra 25% off your first purchase and a FREE 30 day trial. Simply click here!

    Jefferson Adams
    Celiac.com’s 25 Most Popular Gluten-Free Dessert Recipes
    Image Caption: Image: CC--whity
    Celiac.com 08/31/2018 - We've had more than a few requests to make our most popular gluten-free recipes available with a single click. So, for the first time in one place, here are Celiac.com’s most popular recipes for gluten-free desserts. These recipes have been enjoyed by hundreds of thousands of readers and have anchored more than a few gluten-free tables. They are sure to please even the picky gluten-free eaters. 
    Here are Celiac.com’s most popular gluten-free dessert recipes:
    Cheesecake with Gluten-free Almond Crust
    This cheesecake recipe is not only one of our most popular recipes, it is one of our most widely read and shared features of all time.

    Gluten-Free Chocolate Pudding with Fresh Vanilla Whipped Cream
    This gluten-free chocolate pudding with fresh vanilla whipping cream will have you doing your little chocolate dance and singing your happy tummy song.
    Quick Gluten-Free Cranberry Coconut Cookies
    These gluten-free cranberry coconut cookies are fun to eat, and a snap to make.
    Soft and Chewy Gluten-free Ginger Snaps
    Break out the milk, because this recipe for soft, chewy, gluten-free gingers snaps will have hungry, happy snackers begging for more.
    Tasty Gluten-Free Apple Crisp
    This recipe for super-tasty apple crisp is gluten-free and easy as pie to make.

    Gluten-free Apple Pie and 20 More Recipes for Festive Gluten-free Holiday Treats
    This recipe for a delicious gluten-free apple pie, plus 20 more gluten-free recipes to make your holiday season a homemade gluten-free hit.

    Celiac.com Sponsor: Review
    Celiac.com 08/31/2018 - Until recently the only way to get a proper screening for celiac disease would be to convince your doctor or health care provider to order the tests, and then pay a visit to the lab where they would draw a test tube or two full of blood. Depending on your situation, it can sometimes be difficult to convince your doctor or health care provider to actually order the tests. They can also be expensive, even if you are lucky enough to have decent health insurance coverage.
    Did you know that you can now use a LetsGetChecked home screening kit to carry out a full celiac disease screening in the privacy of your own home?  I recently took the opportunity to use their kit to re-screen my son for celiac disease, as it's been a while since his last screening, and he should be getting screened annually.
    The test kit arrived quickly, and upon opening it I found all the items necessary to collect a specimen, plus a very clear set of eight step-by-step instructions, complete with graphics, to make it super easy to follow. The kit requires “activation,” which was done in just a few minutes on their Web site. The activation process allows the lab to connect you with your specimen, so that you can get your results via their Web site. 
    After activating my kit we moved on to the specimen collection, which went far easier than I expected. The kit comes with a few lancets, and we used only one of them to painlessly prick my son's finger. We gathered around 8 or 9 drops of his blood to fill the collection tube. After snapping the lid on it, we put it in the addressed, stamped envelope and dropped it off at our local UPS Store.
    A few days later I was surprised to get a call from a their medical team who took the time to go over my son's results with me over the phone—which, happily for my son—were negative! I also received an email with the results, and I was able to view them on their Web site as well.
    Whether you want to save money, wish to have more privacy with your testing and results, or would like to get screened quickly—using LetsGetChecked kit to screen for celiac disease makes a lot of sense. I've already recommended it to several friends and family members, and believe that this is one of the best home test kits available, and will be a big part of the future of celiac disease screening. 

    Antonio Tursi, M.D.
    Endoscopy in Celiac Disease
    Image Caption: Image: CC--Andy G
    Celiac.com 08/30/2018 - Celiac disease is a disorder characterized by a clinical syndrome of intestinal malabsorption and a characteristic though not specific histological lesion consisting in total, subtotal or partial small-bowel villous atrophy (predominating in the proximal segments).  A correct gluten-free diet results in clinical and histological improvement(1,2).  It has become increasingly apparent that the prevalence of celiac disease is higher than previously thought, and that this is mainly because of increasing awareness of atypical, mildly symptomatic, or silent cases(3).  Therefore, many patients have upper gastrointestinal endoscopy as an initial investigation, which provides an opportunity to perform a biopsy in the second portion of the duodenum.  
    The role of endoscopy in diagnosing celiac disease
    It has long been known that celiac disease can produce changes in the appearance of small intestine on barium contrast radiographs, one such change being so-called “loss” of duodenal folds.  However, over the last two decades it has been recognized that a number of changes in the duodenum clearly associated with celiac disease can be identified endoscopically.  Because it is now understood that the manifestations of celiac disease are wide and variable, and that the disease is more common than recognized in the past, the clinical significance of these endoscopic observations has been greatly amplified.  Awareness of these endoscopic features may alert the endoscopist to the presence of celiac disease and the need for duodenal biopsies in patients undergoing endoscopy for symptoms unrelated to the disease as well as those with vague, non-specific manifestations.
    The endoscopic features in the duodenum that are well-established as markers for celiac disease include: loss of folds; scalloping of folds; mucosal mosaic pattern; whilst less commonly described findings include a visible vascular pattern and micronodularity in the duodenal bulb.
    1.    Loss of folds
    “Loss” of folds is defined as an obvious reduction in height or number of folds in the second portion when viewed with maximal air insufflation.  The sensitivity and specificity of this marker range from 73 to 88% and from 83 to 97% respectively (4,5).
    2.    Scalloping of duodenal folds
    Scalloping occurs when multiple grooves run over the apex of a duodenal fold.  Grooves in the mucosa between folds have also associated with celiac disease and likely a manifestation of the same process that leads to scalloping.  The sensitivity and specificity of this marker are 88% and 87% respectively (6,7).
    3.    Mucosal mosaic pattern
    Mucosal mosaic pattern may be recognized both in the duodenal bulb and in the second portion of the duodenum, and its assessment may be easily performed by chromoendoscopy.  Unfortunately, the sensitivity of this marker is quite low (57%) (8).
    4.    Micronodularity in duodenal bulb
    This marker is quite frequent in childhood and adolescent patients, but it can be also recognized in young adults 9-11.  
    5.    Visible vascular pattern
    This marker describes a prominence of underlying duodenal blood vessels in patients with celiac disease.  Unfortunately, this is the least sensitive endoscopic marker in all studies in which it was specifically evaluated (6,12,13).  
    All these markers are helpful in recognising celiac disease.  Moreover, in some cases specific endoscopic features can be associated with specific histological damage and may be associated with the clinical form of the disease.  We found in fact that endoscopic appearance of the duodenum may be predictive of histological damage grading.  Moreover, we showed that in young patient with subclinical/silent celiac disease there is a greater probability of finding slight/mild endoscopic abnormal/mild histological damage (11).
    Unfortunately, an endoscopic marker suspected for celiac disease itself is not specific for celiac disease.  For example, looking at scalloping, Shah, et.  al., described 13 cases in which scalloping of duodenal folds was not caused by celiac disease but due to other causes (HIV-related infection, tropical sprue, giardiasis, eosinophilic gastroenteritis)(14).
    On the other hand, the presence of one or more endoscopic markers increases the sensitivity and specificity ranging from 87.5 to 94%  and from 99 to 100% respectively (12,15).   
    There is non-existing classification of endoscopic lesions in celiac disease.  However, I think that it may be graded according to some simple considerations.  Celiac disease is considered a crianial-caudal disease which affects primarily the proximal segments (first the duodenal bulb and then the second and third duodenal portions) and then the distal segments of the small bowel (first jejeunum and then the ileum).  Therefore, we may hypothesize that endoscopic damage occurs first in the duodenal bulb and then in the distal tracts of the duodenum.  For this reason, and according to other endoscopists in Italy, I proposed the following classification in 2002(11):
    a.    Slight/mild endoscopic damage: micronodular bulb, granular mucosa of the second duodenal portion, scalloping of duodenal folds, reduction of duodenal folds; b.    Severe damage: “mosaic” pattern of the duodenal mucosa, visible vascular pattern, loss of duodenal folds. The effectiveness of this grading system was confirmed in the same study.  In fact we found that  the so-called “slight-mild endoscopic damages” seen at endoscopy was associated with a mild-moderate histological damage (p<0.005), while the so-called “severe endoscopic damages” was related to severe histological damage (p<0.0005).  Unfortunately, no Consensus Conference on celiac disease has discussed this problem yet.         
    New endoscopic methods
    Several new endoscopic techniques have been recently developed to increase the sensitivity and specificity of endoscopy in diagnosing celiac disease.
    a.    “Immersion” technique.
    The “immersion” technique consists in observing duodenal mucosa using a high-resolution, high-magnifying (x2) videoendoscope that observes the villous architecture with a water film.  This approach seems to be effective in allowing the visualization of duodenal villi and the detection of total villous atrophy(16).  A recent study found that this approach is highly accurate in detecting total villous atrophy in suspected celiac cases, and it seems both accurate and cost-sparing to diagnose celiac disease in subjects with marked duodenal villous atrophy, having a sensitivity, specificity, and positive and negative predicting values of 100%17.  Moreover, this approach also seems to be effective in detecting patchy villous atrophy in celiac patients with patchy lesions (18).
    b.    Zoom endoscopy
    This technique provides a very impressive magnification capability of x115.  This approach may allow the macroscopic detection of unrecognised villous atrophy in patients with unsuspected celiac disease.  Badreldin, et.  al., found recently that zoom endoscopy may be valuable in assessing degree of villous atrophy, having a positive predicting value of 83% and a negative predicting value of 77% in detecting villous atrophy (19).
    c.    Double-balloon endoscopy (DBE)
    This technique will become probably the best endoscopy technique in investigating small bowel.  It allows high-resolution visualization, biopsies and therapeutic interventions in all segments of the GI tract.  DBE is a safe and feasible diagnostic and therapeutic tool for suspected or documented small-bowel diseases.  However, it requires a long time for small bowel exploration (about 70 minutes from the oral route and  about 90 minute from the anal route) and requires expertise personnel to obtain better results 20.  At present, the best candidates for the procedure appear to be those with obscure GI bleeding.           
    d.    Wireless capsule endoscopy
    Celiac disease is an inflammatory disease that involves the entire small intestine.  Even in the 1960s was documented, by using peroral biopsies, that the inflammatory atrophic process can extend a variable distance down the small intestine, not uncommonly involving the ileum(21).  These data have been recently confirmed by endoscopic studies, that found ileal inflammatory changes predicting villous atrophy in duodenal biopsy specimens(22).
    Wireless capsule endoscopy is a new effective and easy method to investigate small bowel.  The M2A video capsule endoscope (Given Imaging LTd; Yokneam, Israel) is a wireless capsule (11 mmx27 mm) comprised a light source, lens, CMOS imager, battery and a wireless transmitter.  The slippery out side coating of the capsule allows easy ingestion and prevents adhesion of intestinal contents, while the capsule moves via peristalsis from mouth to anus.  The battery provides seven to eight hours of work in which the capsule photographs two images per second (between 50,000-60,000 images all together), which are transmitted to a recorder which is worn on the belt.  The recorder is downloaded into a computer and seen as a continuous video film.  Since its development additional support systems have been added, a localization system, a blood detector and a double picture viewer.  All of this is intended to assist the interpreter of the film and to shorten the reviewing period.
    The full range of indications for CE became apparent with time.  The initial device was invented to address for a better diagnostic tool for small bowel pathologies (such as obscure gastrointestinal bleeding or Crohn’s disease)(23).  In light of this high specificity for the diagnosis of small bowel diseases, it is considered that capsule endoscopy may be of value in the diagnosis of celiac disease for patients with a positive endomysial or tissue transglutaminase antibody and who are unable to or unwilling to undergo EGDscopy(24).  The very important limit of this new technique in celiac disease is represented by the absence of histological-proven damage.  It is recognised that the endoscopic signs of villous atrophy are not sensitive for the lesser degrees of villous atrophy, so partial villous atrophy may be missed by this approach(13).
    On the other hand, I think that the patients who appear to be ideal candidates for capsule endoscopy are those patients who fail to respond to a gluten-free diet, or who develop alarm symptoms while on a gluten-free diet.  These patients often undergo extensive radiologic, and sometimes, surgical evaluation, because of concern for the development of complications (such as lymphoma(25,26) or ulcerative jejunitis(27).  It is clear that lesions detected by capsule endoscopy in this high-risk group will require further evaluation of these abnormalities through biopsy.  Capsule endoscopy may thus be used to select patients to undergo enteroscopy(28) or, more probably in the near future, double-balloon endoscopy(29).  
    The role of endoscopy in the follow-up of celiac disease
    Data on small-intestinal recovery in patients with celiac disease are scarce and contradictory.  This is especially the case for adult patients, who often show incomplete histological recovery after starting GFD.  On the other hand, there are very few data about the endoscopic recovery on GFD.  We recently conducted a two-year prospective study on 42 consecutive adults with newly diagnosed celiac disease.  All the patients underwent EGDscopy and small-bowel biopsy.  A normal endoscopic appearance (absence or mucosal irregular findings, normal duodenal folds)  was found in 76.2% after two-year on a GFD.  Subdividing the patients according to age, patients aged from 15 to 60 years showed significant improvement within 12 months but faster in patients in patients <45 years, whereas the improvement in endoscopic findings in patients older than 60 years was not statistically significant even 24 months after starting GFD.  On the contrary, histological recovery was much more slower, since only younger patients (5-30 years) showed significant improvement of histology within 24 months(30).  These data showed for the first time that endoscopic recovery is faster than histological recovery after starting GFD.  
    Conclusive Advice
    A number of studies have demonstrated a strong correlation between the endoscopic duodenal findings and celiac disease.  Furthermore, absence of specific features suspected from celiac disease does not exclude celiac disease and specimens should always be obtained when there is a suspicion that the disease may be present.  For this reason, capsule endoscopy should be not recommended as first endoscopic step in searching celiac disease, but it may be best used to recognize endoscopic recovery and to exclude complication in celiac patients on GFD.  
    The last question is: How long should we continue with endoscopic and histological follow-up? Looking at the results recently obtained from our group, my advice on follow-up could be summarized as follows: patients aged under 30 years should undergo endoscopic/histological assessment after one year; patients aged 30-45 years should be reassessed after two years; and patients aged 50 years and over should be reassessed after two years, including an immunohistological assessment to exclude refractory celiac disease.
    References:
    1)    Martucci S, Biagi F, Di Sabatino A, Corazza GR.  Coeliac disease.  Digest Liver Dis 2002;34 (suppl.  2): S150-S153.
    2)    When is a celiac a celiac? Report of a working group of the United European Gastroenterology Week in Amsterdam, 2001.  Eur J Gastroenterol Hepatol 2001;13: 1123-8.
    3)    Tursi A, Giorgetti GM, Brandimarte G, Rubino E, Lombardi D, Gasbarrini G.  Prevalence and clinical presentation of subclinical/silent coeliac disease in adults: an analysis on a 12-year observation.  Hepato-gastroenterol 2001; 39: 462-4.
    4)    Brocchi E, Corazza G, Caletti G et al.  Endoscopic demonstration of loss of duodenal folds in the diagnosis of celiac disease.  N Engl J Med 1988;319: 741-4.
    5)    Mc Intere AS, Mg DP, Smith JA , Amoah J, Long RG.  The endoscopic appearance of duodenal folds is predictive of untreated adult celiac disease.  Gastrointest Endosc 1992;38: 148-51.
    6)    Corazza GR, Caletti GC, Lazzari R et al.  Scalloped duodenal folds in childhood celiac disease.  Gastrointest Endosc 1993; 29: 543-5.
    7)    Smith AD, Graham I, Rose JD.  A prospective endoscopic study of scalloped folds and grooves in the mucosa of the duodenum as sign of villous atrophy.  Gastrointest Endosc 1998;47: 461-5.
    8)    Stevens FM, McCarthy CF.  The endoscopic demonstration of coeliac disease.  Endoscopy 1976;8: 177-80.
    9)    Brocchi E, Corazza GR, Brusco G, Mangia L, Gasbarrini G.  Unsuspected celiac disease diagnosed by endoscopic visualization of duodenal bulb micronodules.  Gastrointest Endosc 1996;4: 610-1.
    10)    Vogelsang H, Hänel S, Steiner B, Oberhuber G.  Diagnostic duodenal bulb biopsy in celiac disease.  Endoscopy 2001;33: 336-40.
    11)    Tursi A, Grandimarte G, Giorgetti GM, Gigliobianco A.  Endoscopic features of celiac disease in adults and their correlation with age, histological damage, and clinical form of the disease.  Endoscopy 2002;34: 787-92.
    12)    Niveloni S, Fiorini A, Dezi R et al.  Usefulness of videoduodenoscopy and vutal dye staining as indicators of mucosal atrophy of celiac disease: assessment of interobserver agreement.  Gastrointest Endosc 1998;47: 223-9.
    13)    Dickey W, Hughes D.  Disappointing sensitivity of endoscopic markers for villous atrophy in a high-risk population: inplication for celiac disease diagnosis during routine endoscopy.  Am J Gastroenterol 2001;96: 2126-8.
    14)    Shah VH, Rotterdam H, Kjotler DP, Fasano A, Green PH.  All that scallops is not celiac disease.  Gastrointest Endosc 2000;51: 717-20.
    15)    Dickey W, Hughes D.  Prevalence of celiac disease and its endoscopic markers among patients having routine upper gastrointestinal endoscopy.  Am J Gastroenterol 1999;94: 2182-6.
    16)    Cammarota G, Martino A, Pirozzi GA et al.  Direct visualization of intestinal villi by high-resolution magnifying upper endoscopy: a validation study.  Gastrointest Endosc 2004;60: 732-8.
    17)    Cammarota G, Cesaro P, Martino A et al.  High accuracy and cost-effetciveness of a biopsy-avoiding endoscopic approach in diagnosing celiac disease.  Aliment Pharmacol Ther 2006;23: 61-9.
    18)    Cammarota G, Martino A, Di Caro S et al.  High-resolution magnifying upper endoscopy in a patient with patchy celiac disease.  Dig Dis Sci 2005;50: 601-4.
    19)    Badreldin R, Barrett P, Wooff DA, Mansfield J, Yiannakou Y.  How good is zoom endoscopy for assessment of villous atrophy in coeliac disease? Endoscopy 2005;37: 994-8.
    20)    Di Caro S, May A, Heine DG, Fini L et al.  The European experience with bouble-balloon enteroscopy: indications, methodology, safety, and clinical impact.  Gastrointest Endosc 2005;62: 545-50.
    21)    MacDonald WC, Brandiborg LL, Flick AL et al.  Studies of celiac sprue.  IV.  The response of the whole length of the small bowel to a gluten-free diet.  Gastroenterology 1964;47: 573-89.
    22)    Dickey W, Hughes DF.  Histology of the terminal ileum in coeliac disease.  Scand J Gastroenterol 2004;39: 665-7.
    23)    Eliakim R.  Wireless capsule video endoscopy: three years experience.  World J Gastroenterol 2004;10: 1238-9.
    24)    Cellier C, Green PH, Collin P et al.  The role of capsule endoscopy in coeliac disease: the way forward.  Endoscopy 2005;37: 1055-9.
    25)    Green PH, Fleichauer AT, Baghat G et al.  Risk of malignancy in patients with celiac disease.  Am J Med 2003;115: 191-5.
    26)    Cellier C, Delabasse E, Helmer C et al.  Refractory sprue, coeliac disease and enteropathy-associated T-cell lymphoma.  French Coeliac Disease Study Group.  Lancet 2000;356: 203-8.
    27)    Green JA, Barkin JS, Gregg PA et al.  Ulcerative jejunitis in refractory celiac disease: enteroscopic visualization.  Gastrointest Endosc 1993;39: 584-5.
    28)    Gay G, Delvaux M, Fassler I.  Outcome of capsule endosocpy in determining indication and route for push-and-pull enteroscopy.  Endoscopy 2006;38: 49-58.
    29)    Yamamoto H, Kita H, Sunada K et al.  Clinical outcomes of double-baloon endoscopy for the diagnosis and treatment of small-intestinal diseases.  Clin Gastroenterol Hepatol 2004;2: 1010-6.
    30)    Tursi A, Brandimarte G, Giorgetti GM.  Endoscopic and histological findings in the duodenum of adults with celiac disease before and after changing to a gluten-free diet: a 2-year prospective study.  Endoscopy 2006; 38: in press.

    Jefferson Adams
    Case Study Indicates That CD8+, Perforin+ and Granzyme B+ Infiltrate the Cerrebullum in Gluten Ataxia
    Image Caption: Image: CC--Anna Shcherbina
    Celiac.com 08/29/2018 - Up to one in twelve patients with gluten sensitivity develops neurological symptoms such as ataxia, dementia, seizures or peripheral neuropathy, though the reasons for this are still poorly understood.
    As a means of better understanding the immunological mechanisms behind this reality, a team of researchers recently reported the case of a 68‐year‐old male patient suffering from progressive ataxia and dementia associated with chronic diarrhea, and both elevated IgG and IgA antigliadin‐antibodies. 
    The research team included Michel Mittelbronn, Jens Schittenhelm, Gellert Bakos, Rob A. De Vos, Manfred Wehrmann, Richard Meyermann, and Katrin Bürk. They are variously affiliated with the Institute of Brain Research at the University of Tübingen, and the Institute for Cell Biology, Department of Immunology at the University of Tübingen, Tübingen, Germany, the Neurological Institute/Edinger Institute, Goethe University Medical School, Frankfurt, the Department of Pathology, St. Georg Hospital, Leipzig, Germany, and with the Laboratory for Pathology, Enschede, the Netherlands.
    Autopsy indicated that frequent argyrophilic glial and neuronal inclusions within the basal nucleus of Meynert were the structural markers of the cognitive decline.  The patient showed substantial neuronal loss in the cerebellar cortex and the inferior olives, along with infiltrating CD8+/perforin+/granzyme B+ cells, and reactive astrogliosis and microglial activation. 
    In patients with gluten sensitivity and neurological disease, it is likely that CD8+ cytotoxic T and NK cells function as effector cells that trigger neuronal cell death, and thus might play some role in triggering cerebellar symptoms in gluten ataxia cases. The team concludes by noting that an absence of B‐ or plasma cells, along with multiple CD8+, granzyme B and perforin expressing cells in ataxia‐associated brain areas, indicates pronounced cytotoxic effects in neuro-pathogenesis of gluten sensitivity.
    This is one of the first reports to indicate that CD8+, perforin+, and granzyme B+ effector cells infiltrate the cerebellum and inferior olives in cases of gluten ataxia.
    Read more in: Neuropathology

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    To get your own Nima Starter Kit and stay up-to-date with the latest Nima news and events, visit their site.

    Jefferson Adams
    Comprehensive Review Shows No Higher Rates of Celiac Disease in Osteoporosis Patients
    Image Caption: Image: CC--i_vaquera
    Celiac.com 08/28/2018 - There have been a number of studies that tried to estimate risk levels for celiac disease in patients with osteoporosis, but the data has been highly variable and inconclusive. To address this, a team of researchers recently set out to investigate rates of celiac disease among individuals with osteoporosis.
    The research team included M. Laszkowska, S. Mahadev, J. Sundström, B. Lebwohl, P. H. R. Green, K. Michaelsson, and J. F. Ludvigsson. They are variously affiliated with the Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA, the Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University in Uppsala, Sweden, the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet in Stockholm, Sweden, the Department of Paediatrics, Örebro University Hospital in Örebro, Sweden, and with the Division of Epidemiology and Public Health, School of Medicine, University of Nottingham in Nottingham, UK. 
    The team conducted a systematic review of articles that appeared in PubMed, Medline or EMBASE through May 2017 to find studies on rates of celiac disease in patients with osteoporosis. Search terms included “coeliac disease” combined with “fractures”, “bone disease”, “bone density”, “densitometry”, “osteoporos*”, “osteomal*”, “osteodys” or “dexa” or “dxa” or “skelet”. Non‐English papers with English‐language abstracts were included. 
    To confirm their data, the team used fixed‐effects inverse variance‐weighted models, and tested heterogeneity through both subgroup analysis and meta‐regression. They found a total of eight relevant studies, containing data from 3,188 people with osteoporosis. From this group, the team found 59 individuals, or just under 2%, with celiac disease.
    A weighted pooled analysis showed biopsy‐confirmed celiac disease in 1.6% of osteoporosis patients. 
    The team found moderate heterogeneity (I2 = 40.1%), which was influenced by the underlying celiac disease rates in the general population. After adding four studies covering a total of 814 people with celiac disease, based on positive tissue transglutaminase or endomysial antibodies, the pooled rate was comparable (1.6%; 95% CI = 1.2%‐2.0%).
    About 1.6% of people with osteoporosis have biopsy‐verified celiac disease. That’s about the same rate as the general population. Based on this data, the team sees no need to routinely screen osteoporosis patients for celiac disease, contrary to current guidelines. They suggest additional studies to assess the benefits and desirability of such screening programs.
    So, it looks like there’s no reason for people with osteoporosis, or their doctors, to be concerned about celiac disease unless patients shows some physical symptoms or signs.
    Read more in: Alimentary Pharmacology & Therapeutics

    Jefferson Adams
    Seronegative Celiac Disease
    Image Caption: Image: CC--julietka and snoop
    Celiac.com 08/27/2018 - Imagine the difficulty of diagnosing celiac disease without the associated blood antibodies, with seemingly normal blood tests. Seronegative celiac disease is one of the most common causes of seronegative villous atrophy, so a biopsy is crucial in such cases, but it can be hard for doctors to justify a biopsy in the face of seemingly normal blood tests. How can researchers learn more?
    Seronegative celiac disease seems like a simple enough condition. It's just the presence celiac disease without the celiac-associated blood antibodies typically found in people with the disorder. Isn't it? Well, not exactly. For one thing, seronegative celiac disease is rare, and the little data that exist are contradictory. Some data has even indicated that seronegative enteropathies have lead to higher rates of death than standard celiac disease.
    Yet, seronegative celiac disease remains poorly defined, partly from an absence of consensus on an exact definition, and partly due to an imprecise use of specific celiac serology. Due to these factors, accurate celiac diagnosis can be extra difficult in patients with seronegative celiac disease. Even when doctors spot seronegative villous atrophy, they still need to exclude other enteropathies as a potential cause. 
    To try to shed some light on the nature of seronegative celiac disease, a team of researchers recently set out to provide a critical summary of the most recent work on this topic, along with a working definition of seronegative celiac disease. The research team included A Schiepatti, DS Sanders, and F Biagi. They are variously affiliated with the Coeliac Centre/First Department of Internal Medicine, University of Pavia, Pavia, Italy, and with the Academic Department of Gastroenterology, Royal Hallamshire Hospital & University of Sheffield, UK.
    Finding an accepted definition of seronegative celiac disease is crucial in order to ensure that patients receive a correct diagnosis, and thus avoid inappropriate treatment, and the perils associated with long-term untreated celiac disease.
    Since cases of seronegative celiac disease are commonly dealt with individually, it is important to establish strict criteria for the diagnosis of seronegative celiac disease to ensure prompt identification and treatment of these celiac patients. Doing so will require further study, along with input from the scientific community.
    Source:
    Curr Opin Gastroenterol. 2018 May;34(3):154-158.

    Jefferson Adams
    Asian-style Gluten-Free Pork and Cucumber Salad
    Image Caption: Image: CC--Foodista
    Celiac.com 08/25/2018 - Meat makes a great anchor for so many good salads. You’ve got your chicken Caesar, you’ve got your steak salad. This recipe lets you turn a corner and head into fresh territory with ground pork. This simple, easy gluten-free salad is sure to gain fans at your next food gathering. The recipe blends browned ground pork with garlic, ginger, soy sauce, chili pepper and a few other things to make some culinary magic.
    Ingredients:
    1 pound ground pork 1 cup long-grain white rice 1 tablespoon cooking oil 3 cloves garlic, finely chopped 1 small red chili (seeded if desired), finely chopped 2½ tablespoons fresh ginger, grated 2 tablespoons gluten-free soy sauce 5 tablespoons fresh lime juice 1 tablespoon sugar 1 English or Persian cucumber, thinly sliced 2 scallions, thinly sliced 1 cup fresh cilantro ½ cup fresh mint
    Directions:
    Brown ground pork in cast-iron skillet in canola oil, 7 minutes. Toss with garlic, red chili, and 2 tablespoons grated fresh ginger. Remove from heat and toss with 2½ tablespoons lime juice and 1 gluten-free soy sauce.
    In a bowl, stir together 2½ tablespoons lime juice, 1 tablespoon of gluten-free soy sauce, ½ tablespoon grated ginger and sugar. Toss with cucumber and scallions, and then fold in the cilantro and mint. 
    Serve with pork over rice.

    Kate Ozello
    No Halloween Tears Please
    Image Caption: Image: CC--Kevin_Dooley
    Celiac.com 08/24/2018 - Last year was our first gluten-free Halloween and my older son, James (now in 5th grade) got really upset when he realized that he wouldn’t be able to eat a lot of the candy from trick or treat night. He was saying he didn’t want to trick or treat and for awhile wouldn’t pick out a costume. (Prior to this, he loved dressing up and trick-or-treating.)
    We solved this problem by having an unsafe candy auction for both of our boys, at the end of the evening. I went out and bought individual candies that I knew they liked (as opposed to bags of it) and non-food treats (small toys, sillybanz - stuff you might put in their stocking at Christmas). When they came home from trick-or-treating, we emptied their bags and divided the candy up: safe pile and unsafe or questionable pile.
    Then I had my bag of surprise treats - I don’t know if you are a Survivor fan, but I did it kind of like their food auction. I held up something like two containers of cotton candy and asked how many unsafe candies they would pay for it - except unlike Survivor - both boys bought it, not just one. Maybe they would shout out “five candies” - we had a separate bag for the “payment” they “paid” for all the safe candies and treats.
    (My husband took the bag of unsafe candies to work where he was VERY popular.) At the end of the auction, I had something a little bigger, I can’t remember what it was (maybe a ds game?) The “payment” for the last, big treat was the rest of their unsafe candy.
    I hope this helps you as Halloween approaches. My kids loved it and No-one cried.

    Jefferson Adams
    Green Banana Flour Could Be the Key to a Healthier Gluten-Free Future
    Image Caption: Image: CC--Mauren Veras
    Celiac.com 08/23/2018 - With the market for gluten-free goods and ingredients going like gang-busters, the proliferation of new flours made from previously unavailable ingredients is helping to change the product manufacturing landscape and to open up whole new avenues of nutrition, health benefits and flavor for people with celiac disease.
    One of the latest gluten-free flours to hit the market  is banana flour, an alternative to wheat flour that has gained popularity for its light, fluffy baking results. Made of 100% dried, ground green bananas, banana flour is not only gluten-free but also paleo, Whole30-approved, and vegan. Highly nutritious banana flour also touts numerous health benefits.
    In addition to being naturally gluten-free, banana flour is similar in calories to regular white flour, but is made from a completely different type of carbohydrate. While white flour is made from simple starches that are quickly absorbed and turned into energy, banana flour contains high levels of what is called “resistant starch.” Resistant starches are so-called, because they work a bit like soluble fiber, slowing the digestion of carbohydrates, and resisting absorption by the gut. Resistant starches are also found in foods such as whole grains, vegetables, and legumes.
    “Resistant starch has been found to be beneficial for colon health, increasing satiety levels, and lowering blood sugar,” said registered dietitian Amy Margulies.  “Banana flour also contains high levels of phenolic acid, a type of phytochemical found in many plant foods, which works like an antioxidant and supplies both potassium and vitamin B6.”
    Banana flour not only produces light, fluffy baked goods with a good nutrition profile, it is also easy to use. When substituting banana flour for wheat flour in a recipe, simply use about 30% less banana flour.

    Jefferson Adams
    Local Pharmacists Might Need More Training to Help Celiac Disease Customers
    Image Caption: Image: CC--Ninian Reid
    Celiac.com 08/22/2018 - There’s been some data to support the idea that local pharmacists might have an important role to play in helping people with celiac disease to remain gluten-free by providing information about possible gluten in drugs, and even liaising with manufacturers for gluten information on the patient’s behalf, as needed.
    But how solid is your local pharmacist when it comes to celiac disease awareness? A team of researchers recently set out to evaluate pharmacists' knowledge of celiac disease, and to look for areas where further information may be beneficial.
    The research team included Carmela Avena-Woods, PharmD, BS Pharm; Robert A. Mangione, EdD; and Wenchen Kenneth Wu, PhD, MBA. They are all with St. John's University in Queens, New York. To gather data for their evaluation, their team sent a survey to community pharmacists who practice in a national chain pharmacy in one region of New Jersey and New York.
    A total of 418 pharmacists, just under 40%, responded to the survey. Sixty percent of the responses correctly noted that there are currently no federal regulations requiring manufacturers to designate medications as gluten-free. Still, forty percent got that wrong. Perhaps most alarmingly, of the pharmacists who claimed a basic or advanced understanding of celiac disease, only 27% correctly indicated that celiac disease is both an autoimmune and a chronic lifelong disease. 
    Interestingly, twenty percent of pharmacists said they often suggested a change of diet to people with suspected celiac disease before a clinical diagnosis was made.
    This study suggests that community pharmacists have some understanding of celiac disease, but that additional celiac education is advisable if they are to play an integral role in helping people with celiac disease to maintain a gluten-free diet.
    Read more at: Am J Pharm Educ. 2018;82(2)
     

    Jefferson Adams
    Latest Study Says Celiac Disease Reduces Ovarian Reserves
    Image Caption: Image: CC--Thomas van de Weerd
    08/21/2018 - Does celiac disease have any kind of adverse effect on ovarian reserve levels in women of reproductive age? To get an answer, a team of researchers recently conducted a study of ovarian reserve in patients of reproductive age with celiac disease using anti-Müllerian hormone (AMH) levels, antral follicle counts (AFCs), and ovarian volume.
    The research team included Erol Cakmak, Savas Karakus, Ozlem Demirpence, and Banu Demet Coskun. They are variously affiliated with the Department of Gastroenterology, the Department of Obstetrics and Gynecology, the Department of Biochemistry, Cumhuriyet University Faculty of Medicine, Sivas, Turkey, and with the Department of Gastroenterology, Kayseri Training and Research Hospital in Kayseri, Turkey.
    For this study, their team included 46 female celiac patients and 40 healthy female subjects of reproductive age, 18–45 years of age. 
    The team drew blood samples from both groups on days 2–4 of the menstrual cycle, and measured follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), prolactin (PRL), and AMH levels. On the same day, the team measured AFCs and ovarian volume for each patient. They also recorded patient body mass index (BMI), gravidity/parity/abortions/alive counts, disease duration, and Marsh histological classification.
    The results showed no statistically significant differences between celiac disease patients and control groups in terms of mean age, BMI, or median gravidity/parity/abortions/alive counts.  Also, there were no statistically significant differences between the groups in terms of average FSH, LH, E2, PRL levels, right and left ovarian volumes, and median right and left ovarian AFCs. 
    The team found AMH levels to be markedly lower in the celiac group. The Spearman correlation test showed no significant connection between AMH levels and age, BMI, FSH, LH, E2, PRL levels, right and left ovarian volumes, right and left ovarian AFCs, or Marsh histological classification.
    However, the team did find that, compared to healthy controls, female celiac patients of reproductive age showed decreased AMH levels and ovarian reserves that reflected the length of celiac duration; the longer the celiac disease, the greater the decrease.
    It appears that, especially over time, celiac disease can reduce ovarian reserves, which could have an adverse affect on fertility. 
    Read more at:  Med Sci Monit. 2018; 24: 1152–1157.
     

    Jefferson Adams
    Food Knowledge and Mental Stress Are Big Predictors of Gluten‐Free Diet Success
    Image Caption: Image: CC--Lefteris Heretakis
    Celiac.com 08/20/2018 - Following a gluten-free diet is critical for people with celiac disease. However, the factors that influence gluten-free diet success for people with celiac disease are not well understood on a population-wide scale.
    A team of researchers recently set out to assess the factors that influence gluten‐free diet adherence in patients with celiac disease. The research team included E. P. Halmos, M. Deng, S. R. Knowles, K. Sainsbury, B. Mullan, and J. A. Tye‐Din.
    The team asked celiac patients to complete an online survey that included the validated Celiac Dietary Adherence Test, along with questions on demographics, details of diagnosis and management and assessment of diet knowledge, quality of life and psychological distress. The team then reviewed the survey data for predictors of adherence and quality of life.
    There were a total of 7,393 survey responses, with 5,310 people completing the Celiac Dietary Adherence Test, and 3,230 of whom were following a gluten‐free diet. 
    Multivariate regression showed that predictors of gluten-free dietary adherence included older age, being male, symptoms severity after gluten consumption, above average gluten-free food knowledge, and lower risk of psychological distress. People with celiac disease who followed a gluten-free diet also reported better quality of life. 
    Respondents who reported having poor food knowledge were more likely to wrongly identify gluten‐free foods, though they could still recognize gluten‐containing foods. This indicates that poor overall food knowledge may lead people with celiac disease to over‐restrict their diet. Poor understanding of gluten‐free diet and stressful psychological well-being were the main modifiable risk factors for failure to follow a gluten‐free diet in patients with celiac disease. 
    From these responses, the team concluded that access to a dietitian and mental health care professional, in cases of psychological stress, is likely necessary to improve gluten-free dietary observation, and thus to improve overall patient health and well-being.
    Read more at: Alimentary Pharmacology & Therapeuticsdoi.org/10.1111/apt.14791
     
    The researchers in this study are variously affiliated with the Department of Gastroenterology, The Royal Melbourne Hospital in Parkville, Victoria, Australia, the Department of Gastroenterology, Central Clinical School, Monash University in Melbourne, Victoria, Australia, the Cartovera Pty. Ltd. in Adelaide, SA, Australia, the Department of Psychological Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology in Hawthorn, Victoria, Australia, the Department of Mental Health, St Vincent's Hospital in Fitzroy, Victoria, Australia, the Department of Psychiatry, University of Melbourne in Parkville, Victoria, Australia, Institute of Health and Society, Faculty of Medical Sciences, Newcastle University in Newcastle Upon Tyne, UK, the Health Psychology & Behavioural Medicine Research Group, School of Psychology, Curtin University in Bentley, WA, Australia, the Immunology Division, The Walter and Eliza Hall Institute of Medical Research in Parkville, Victoria, Australia, and the Department of Medical Biology, University of Melbourne in Parkville, Victoria, Australia.

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    • Maureen and Cyclinglady, Of the foods you listed. . .. I would focus on the Chocolate. Chocolate has Tyramine in it and it could/can cause rashes that  might be confused for DH. Sometimes Tyramine get's confused for/in high sulfite foods as triggers. Here is a great overview article on this topic. http://www.chicagotribune.com/lifestyles/health/sc-red-wine-headache-health-0608-20160525-story.html you might also have trouble with headaches if it tyramine is causing you your trouble. People who have trouble Tyramine might also have trouble with consuming cheeses. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738414/ As for the Milk causing/triggering your DH don't rule Adult onset dairy allergy. While rare it does occur in the literature/research when you search it out. I am including the research here in the hopes it might help you or someone else entitled "Adult onset of cow's milk protein allergy with small‐intestinal mucosal IgE mast cells" https://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.1996.tb04640.x It is generally thought most of grow out of a Milk Allergy at approx. 3 years old. But for some lucky one (I guess) we never do apparently.  (I speak for my friend on this board JMG).  He found out he was having trouble with dairy as an adult better never realized until about 6 months ago. With delayed onset allergies it is often hard to tell if it (allergen) is effecting us because we might not associate it with our dairy consumption because it might happen a day or two latter. See this WHFoods article about food allergens/sensitivies.  It is very long/exhaustive but it is very helpful if you have time to study it in more detail. http://www.whfoods.com/genpage.php?pfriendly=1&tname=faq&dbid=30 I will quote some key points for your information. Symptoms of Food Allergies "The most common symptoms for food allergies include vomiting, diarrhea, blood in stools, eczema, hives, skin rashes, wheezing and a runny nose. Symptoms can vary depending upon a number of variables including age, the type of allergen (antigen), and the amount of food consumed. It may be difficult to associate the symptoms of an allergic reaction to a particular food because the response time can be highly variable. For example, an allergic response to eating fish will usually occur within minutes after consumption in the form of a rash, hives or asthma or a combination of these symptoms. However, the symptoms of an allergic reaction to cow's milk may be delayed for 24 to 48 hours after consuming the milk; these symptoms may also be low-grade and last for several days. If this does not make diagnosis difficult enough, reactions to foods made from cow's milk may also vary depending on how it was produced and the portion of the milk to which you are allergic. Delayed allergic reactions to foods are difficult to identify without eliminating the food from your diet for at least several weeks and slowly reintroducing it while taking note of any physical, emotional or mental changes as it is being reintroduced." Here is their information on Tyramine's. Tyramine "Reactions to tyramine (an amino acid-like molecule) or phenylalanine (another amino acid-like molecule) can result from eating the following foods: Fermented cheeses Fermented Sausage Chocolate Sour Cream Red wine Avocado Beer Raspberries Yeast Picked Herring Symptoms of tyramine intolerance can include urticaria (hives), angioedema (localized swelling due to fluid retention), migraines, wheezing, and even asthma. In fact, some researchers suggest that as many as 20 percent of migraines are caused by food intolerance or allergy, and tyramine intolerance is one of the most common of these toxic food responses." Here is an old thread on tyramine and especially how it can trigger headaches. https://www.celiac.com/forums/topic/95457-headache-culprit-is-tyramine/ I would also suggest your research a low histamine food diet.  Rashes/hives etc. can be triggered my disregulaton of histamine in the body. The other thing in chocolate that might be causing your problems is Sulfites. Here is a website dedicated to a Sulftie allergy. http://www.allergy-details.com/sulfites/foods-contain-sulfites/ Chocolate bars are on their list of sulfite contaning foods but probably most noted in dried fruits and red wine. Knitty Kitty on this board knows alot about a sulfite allergy. I want to go back to the possible dairy allergy for a second as a possible trigger. . .because it has been established as connected to DH . . .it is just not well known. Here is current research (as I said earlier) most dairy allergies are studied in children but it does occur in approx. 10 pct of the GP unless your of Asian descent where it is much more common. https://www.ncbi.nlm.nih.gov/pubmed/29555204 quoting the new research from this year on children. "When CMP (Cow's Milk Protein) was re-introduced, anti-tTG increased, and returned to normal after the CMP was withdrawn again." and if adults can also (though rarely) it seem develop "Adult onset of cow's milk protein allergy with small‐intestinal mucosal IgE mast cells" (see research linked above) as the research shows  you should at least trial removing dairy from your diet if you haven't already and see if your DH doesn't come back when you re-introduce it. It just takes 15 or 20 years for medical doctor' to incorporate new research/thinking into clinical practice.  And note the research on this happening in adults is 20+ years old and as far I know doctor's . . . are not aware of this.  I know I wasn't until recently and I research things alot of to help myself and my friends. But I know you can't do what you don't know about.  So this is why I am trying to share what I learned so that other might be helped and this research might not  lay hidden another 20 years before doctor's and their Celiac/DH patients become aware of it. And if it helps you come back on the board and let us know so it can help others too! If it helps you it will/can help someone else! if they know it helped you then they will/can have hope it might help them too and why I share and research these things for others'. . . who don't know or don't have time to research this for themselves. I hope this is helpful but it is not medical advice. Good luck on your continued journey. I know this is a lot of information to digest at one time but I hope at least some of if it helpful and you at least have a better idea of what in your chocolate could be causing your DH (idiopathic) as the doctor's say (of an unknown cause mild) DH symptom's. Or at least it is not commonly known yet that Milk can also cause trigger (DH) in children and adults who have a Milk allergy undiagnosed. . .because we don't don't typically think  or associate it with adults like maybe we should if we are not of Asian descent. Maureen if this doesn't help you you might want to start a thread in the DH section of the forum. As always  2 Timothy 2: 7   “Consider what I say; and the Lord give thee understanding in all things” this included. Posterboy by the grace of God,
    • I hooe you can get some answers with your new GI doc.
    • Many of us deal with doctor issues and diagnosis, you got a really bad draw indeed. Most doctors dismiss Celiac as their is no money in the cure for them IE a gluten free diet and not medications.

      Keep up updated on your new doctor and testing, good to see you finally found one that listens and can help, I got through on doc #5 I think it was.
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