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INTRODUCTION

Celiac disease, also referred to as celiac sprue or gluten sensitive enteropathy is one of the most common genetic disorders seen in North America (prevalence estimates about 1 per 100-120).^1,2 The disorder is both a form of food allergy and an autoimmune disorder that is readily identified when it presents in its classic form with diarrhea, bloating, distention, weight loss and malabsorption.³ However, celiac disease has more recently been shown to present with other extra-gastrointestinal manifestations: Dermatitis herpetiformis, Iron deficiency, Folate deficiency, Osteopenic bone disease, chronic fatigue, neuropsychiatric manifestations, short stature, infertility, recurrent miscarriages.^4,5 Celiac disease has a common HLA pattern (HLA - DR3-DQ2, -DR5/7-DQ2 and –DR4-DQ8) and commonly seen in association with a number of other autoimmune disorders: IDDM, autoimmune thyroid disease, ulcerative colitis, primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and Sjogren’s syndrome, Table 1. ^6,7,8,9 The gold standard for the diagnosis of celiac sprue requires identification of characteristic histological changes in the small intestine, so called Marsh Criteria, Table 2.¹⁰ Followed by normalization of histological changes after a period of gluten withdrawal.

Table 1. Conditions Associated with Celiac Disease

Table 2. Marsh Criteria

Effective serologic testing has evolved over the last decade to provide reliable non-invasive markers of celiac disease, Table 3.^1,11,12 Screening for celiac disease with these serologic markers among persons suspected of celiac disease has become the standard of practice. However, endoscopy with duodenal biopsy and histological confirmation of Marsh Criteria is still recommended for definitive diagnosis.

Table 3. Serologic Tests For Celiac Disease

Figure 1	Figure 2

The sensitivity and specificity of serologic testing for celiac disease has become so accurate, that some have questioned the need for invasive endoscopic procedure and biopsy. Introduction of videocapsule endoscopy (VCE), a new “non-invasive” method of evaluation the gastrointestinal tract has further advance the notion that conventional “tube-guided endoscopy” and biopsy may not be necessary in all cases of Celiac disease.¹³ Current videocapsule endoscopy (Given Imaging, Yoqneam, Isreal) provides ~8X magnified view of the intestine and remarkable images of the intestinal lining.¹⁴ Many have identified capsule endoscopic findings that are common with celiac disease. Rondonotti E, et al have conducted a multi-center trial to determine the operating characteristics of the videocpsule endoscopy (VCE) to detect celiac disease among a cohort of persons with suggestive symptoms of celiac disease, positive serologic markers and histological confirmation by Marsh Criteria.¹⁵ The study design, results and conclusions of this study are presented for your review the attached powerpoint presentation.

The results of the study, by Rondonotti E, et al¹⁵ suggest that VCE findings are common among patients with clinical symptoms of biopsy confirmed celiac disease. With the evolution of VCE and its mainstream use by gastroenterologists to evaluate many digestive disorders, it is important to emphasize the VCE characteristics seen in celiac disease and that the current generation of 8x magnification fails to detect mucosal changes in up to 12% of biopsy proven cases.

Bibliography

1. Statement NIH Consensus Development Conference on Celiac Disease . <http://www.consensus.nih.gov/cons/118/118cdc_intro.htm>

2. AGA Institute medical position statement on the diagnosis and management of celiac disease. Gastroenterology. 2006;131;1977-1980.<Related link>

3. Kagnoff MF. Overview and pathogenesis of celiac disease. Gastroenterology. 2005;128:S10-18. <Related link>

4. Green PHR. The many faces of celiac disease: Clinical presentation of celiac disease in the adult population. Gastroenterology. 2005;128:S74-8. <Related link>

5. Trier JS. Celiac sprue and refractory sprue. In: Feldman M, Scharschmidt BF, Sleisinger MH, eds. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease., 6th Ed. Philadelphia: WB Saunders, 1998:1557-73. <Related link>

6. Green PHR and Cellier C. Celiac Disease. New Engl J Med. 2007;357:1731-43.
<Related link>

7. Sidney J, del Guercio MF, Southwood S, et al.: The HLA molecules DQA1*0501/B1*0201 and DQA1*0301/B1*0302 share an extensive overlap in peptide binding specificity. J Immunol 2002, 169:5098-5108. <Related link>

8. Mazzarella G, Maglio M, Paparo F, et al.: An immunodominant DQ8 restricted gliadin peptide activates small intestinal immune response in in vitro cultured mucosa from HLA-DQ8 positive but not HLA-DQ8 negative coeliac patients. Gut 2003, 52:57-62. <Related link>

9. Arentz-Hansen H, McAdam SN, Molberg O, et al.: Celiac lesion T cells recognize epitopes that cluster in regions of gliadins rich in proline residues. Gastroenterology 2002, 123:803-809. <Related link>

10. Marsh MN. Gluten, major histocompatibility complex, and the small intestine: A molecular and immunobiologic approach to the spectrum of gluten sensitivity ("celiac sprue"). Gastroenterology 1992;102(1):330-54. <Related link>

11. Hill ID. What are the sensitivity and the specificity of the serologic tests for celiac disease? Do sensitivity and specificity vary in different populations? Gastroenterology. 2005;128:S25-32. <Related link>

12. Rostom A, Dube C, Cranney A, et al. The diagnostic accuracy of serologic tests for celiac disease: A systematic review. Gastroenterology. 2005;128:S38-46. <Related link>

13. Cellier C, Green PH, Collin P, et al. ICCE Concensus for celiac disease. Endoscopy. 2005;37:1055-9.<Related link>

14. Marmo R, Rotondano G, Piscopo R, et al. Meta-analysis: Capsule enteroscopy vs. Conventional modalities in diagnosis of small bowel diseases. Aliment Pharmacol Ther 2005;22:595-604. <Related link>

15. Rondonotti E, Spada C, Cave D, Pennazio M, Riccioni M, De Vitis I, Schneider D, Sprujevnik T, Villa F, Langeleir J, Arrigoni A, Costamagna G, de Franchis R. Video Capsule Enteroscopy in the Diagnosis of Celiac Disease: A multicenter Study. Am J Gastroenterol. 2007;102;1624-163. <Related link>