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The Role of Microscopic Enteritis in Celiac Disease Malabsorption


New research on microscopic enteritis and celiac disease.

Celiac.com 04/27/2011 - People with microscopic enteritis have microscopic and sub-microscopic changes that are associated with symptoms of gluten sensitive enteropathy, and which lead to micronutrient deficiencies. A team of researchers recently set out to examine microscopic enteritis and the pathomechanism of malabsorption.

The research team included Kamran Rostami, David Al Dulaimi, Mohammad Rostami Nejad, Vincenzo Villanacci, and Mihai Danciu. They are affiliated variously with the School of Medicine, University of Birmingham, UK, the Department of Gastroenterology, Alexander Hospital in Redditch, UK, the Nejad Research Center of Gastroenterology and Liver disease, Shaheed Beheshti University, M.C., in Tehran, Iran, the 2nd Department of Pathology, Spedali Civili, University of Brescia Italy, and the “Gr. T. Popa” University of Medicine and Pharmacy in Iasi, Romania.

Signs of microscopic enteritis include subtle mucosal abnormalities with no pronounced inflammation, villous effacement, erosions or ulcerations when observed with conventional light microscopy.

In cases of microscopic enteritis intraepithelial lymphocytes usually fall within the normal range <25/100 enterocytes (microenteropathy), or increased (lymphocytic enteritis).

Microscopic enteritis is the driving force behind atypical forms of celiac disease, previously known as 'potential' and 'latent' celiac disease. Even when there are no major mucosal changes, systemic, microscopic inflammation is a key player in pathophysiology of micro-nutrient deficiency.

Microscopic enteritis or celiac disease with milder, Marsh 0–II, enteropathy is the most common feature of atypical gluten sensitivity, while celiac disease with macroscopic enteritis, and Marsh IIa–c  is less common.

Importantly, and in contrast to much prevailing belief, symptom severity in celiac disease seems to be unrelated to the degrees or length of affected bowel.

The microenteropathy may eventually develop into pronounced villous atrophy, but one interesting finding was that severe mucosal damage does not necessarily mean worse symptoms. People with mild symptoms can have more severe damage, while those with little or no visible damage can have more severe symptoms.

The finding that nutritional deficiency can be seen in patients presenting with even submicroscopic enteropathy casts doubt on the notion that severe mucosal changes, such as villous atrophy, are the sole driver of malabsorption.

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In fact, more and more, systemic inflammation seems to be the main driver of nutritional deficiency in such cases.

Pro-inflammatory cytokines, such as TNF, appear to act at the enterocyte level, inhibiting the uptake of micronutrients like iron and phosphate. From this, it appears that malabsorption in celiac disease is secondary to inflammation and cytokine stimulation.

This might explain why some patients experience milder, 'atypical' enteropathy that acts just like full-blown celiac disease. In fact, inflammation triggered by gluten-sensitized lymphocytes and cytokine stimulation seems to drive the micronutrient deficiencies in celiac disease patients, with or without villous atrophy.

This finding is supported by several studies that show malabsorption syndrome to be no worse in patients with villous atrophy than in those with microenteropathy (Marsh 0–II).

This theory is further bolstered by the fact that many people suffer from non-symptomatic, silent celiac disease with villous atrophy, and mucosal lesions that persist after years of successful gluten-free treatment.

Over the last few years, the only type of gluten sensitivity doctors have identified is atypical presentation with microenteropathy resulting in micronutrient deficiencies.

However, the team points to recent studies by Kurppa et al., and Ludvigsson et al., that suggest simple changes can improve life quality for celiac disease patients with milder enteropathy.

The researchers feel strongly that patients with milder enteropathy and positive serology may benefit from a gluten-free diet, and that autoantibodies might have a more reliable positive predictive value than histology, especially in early enteropathy.

Diagnosing celiac disease in its early stages, especially with little or no mucosal damage, can be very challenging. However, new studies are paving the way toward a better understanding of gluten sensitivity with microenteropathy. As a result, more patients with microenteropathy, symptoms of micronutrient deficiency and positive serology are being presented with the possible benefits of a gluten-free diet.

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3 Responses:

 
Cristina
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said this on
27 Apr 2011 6:09:46 AM PDT
Very important for celiac people. Thanks

 
Melissa
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said this on
02 May 2011 8:04:31 PM PDT
Excellent information

 
Suzanne
Rating: ratingfullratingfullratingfullratingfullratingfull Unrated
said this on
04 May 2011 6:50:27 PM PDT
Great article. Thanks for sharing this info.




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And this from Consumer Reports: http://www.consumerreports.org/cro/magazine/2012/11/arsenic-in-your-food/index.htm Rice aside, stop giving your kids apple juice too as it can contain high levels of arsenic too! Eat real apples -- not juice.

If I am in a bar and it is super busy, I ask for a "to go" cup. Why? If a dishwasher is not being used (or demand is overwhelming it), bartenders are cleaning all the glasses the old fashioned way ( sinks, wash and rinse with disinfectant). Good for killing bacteria I suppose, but maybe not for removing gluten traces. No bar is going to slow down drink orders ($$$$$) to wait for clean glasses from the dishwasher! Is this all true? I can not say. I am just speaking from experience when I was barmaid 30 years ago before there were dedicated bar dishwashers. http://www.servicethatsells.com/blog/how-to-clean-a-beer-glass/ Even if this is "all in my head", I feel better clutching my "to go" cup and can relax. ?

Check out this page and the advice on rice prep: http://www.bbc.co.uk/programmes/articles/2F1MDzyW55pg97Tdpp7gqLN/should-i-be-concerned-about-arsenic-in-my-rice

Hi Rachel and welcome I think you've found the single best site on the web for help and advice. Hope it's of use to you. I tested negative for celiac so no referral. My experience with NHS however suggests it could be worth phoning your Gastro's office and asking the admin staff there to check on this. Things get overlooked... I would avoid anything with those warnings on. It's a pain in the arse because, for example, it recently appeared on a brand of nuts I like. However having some experience of production and marketing environments that warning will only be going on the pack if someone in the company thinks there's a chance of contamination. There's always other products to choose from so I don't take the chance. Walkers crisps have given me a reaction, yes even the sodding ready salted ones It's something to do with their production processes. I think Gary Lineker may dance through the factory each week spreading handfuls of flour for good luck. Whatever, I now avoid them. My energy levels improved over a few months after the diet. It took longer the second time after my challenge. I was still noticing improvements / weird resolutions of odd symptoms up to 9 months to a year later... Lots of good advice here: All the best! Matt

Ah.... Settles back, dons funny hat, smokes pipe, plays violin, injects heroin etc... I think you need to treat yourself as your own science experiment. If you're ok at home with all of the drinks then you can almost certainly rule out alcohol intolerance and thank your bodies burgeoning super coeliac powers of gluten detection for the reaction. Clearly your powers have grown in the past five years young jedi... In which case maybe there's a drink you can order which would reduce this risk, maybe asking for the bottle and a clean glass, forgoing ice, straws etc, anything to simplify matters and reduce the number of contaminant variables. One thing I'd avoid would be 'mixers' from the shared line. Not because there's gluten filled drinks going through them, typically its just coke, lemonade and soda water, but because the nozzle sometimes dips into the drink that's being filled. Paranoid? Maybe, but I avoid them now and pay the extra for a bottle. A word on glasses. Most bars have a dedicated glass washer and they're good, to a point. I've worked behind a bar in the past and the washers are only on for a very short time, they can run up to 35 times an hour... I've seen lipstick on glasses from them and whilst the chances of contamination are probably slight... Now if you're out for a night at different places, it will be very hard to work out where its happening. So my suggestion is to go out to one bar only and pick a decent one. Speak to a bartender or manager, explain to them just what a special snowflake you are and get one definitely clean glass at the outset then keep it for the evening and just get it refilled. Pick one drink only and stick to it. I'd suggest wine as maybe its easier on the stomach than the bubbly prosecco and you can get the little bottles without any chance of contamination but that may be nonsense See what happens... If you're ok, then you have an answer. You've become more sensitive and your reacting to trace gluten. *removes funny hat, discards pipe, hides syringe...