Search

Non-celiac gluten sensitivity (NCGS), also referred to as non-celiac wheat sensitivity (NCWS), is a clinical syndrome characterized by both intestinal and extra-intestinal symptoms responsive to the withdrawal of gluten-containing food from the diet. The aim of this review is to summarize recent advances in research and provide a brief overview of the history of the condition for the benefit of professionals working in gastroenterology. Academic databases such as PubMed and Google Scholar were searched using key words such as ”non-celiac gluten sensitivity”, “gluten related disorders”, and the studies outlined in reference page were selected and analysed. Most of the analysed studiers agree that NCGS would need to be diagnosed only after exclusion of celiac disease and wheat allergy, and that a reliable serological marker is not available presently. The mechanisms causing symptoms in NCGS after gluten ingestion are largely unknown, but recent advances have begun to offer novel insights. The estimated prevalence of NCGS, at present, varies between 0.6 and 6%. There is an overlap between irritable bowel syndrome and NCGS with regard to the similarity of gastrointestinal symptoms. The histologic characteristics of NCGS are still under investigation, ranging from normal histology to slight increase in the number of T lymphocytes in the superficial epithelium of villi. Positive response to gluten free diet for a limited period (e.g., 6 weeks), followed by the reappearance of symptoms after gluten challenge appears, at this moment, to be the best approach for confirming diagnosis. The Salerno expert criteria may help to diagnose NCGS accurately in particular for research purposes but it has limited applicability in clinical practice.

Elemental diet (ED) has been used widely in the treatment of gastrointestinal disorders, especially with the management of Crohn's disease. This modality of diets provides all essential nutrients, and contains protein in the form of free amino acids that are theoretically easily absorbed. High output ileostomies are a rare but important complications of stoma formation following bowel surgery. Treatments could be challenging and include anti-diarrhoeals, octreotide and proton pump inhibitors. There is very little research regarding the use of elemental diets in the treatment of patients with post-operative high ileostomy outputs. Adequate management of high output ileostomies might prevent significant morbidity. In this case report, we describe a patient who underwent a subtotal colectomy for ulcerative colitis complicated by refractory high ileostomy output despite maximal standard medical therapy for years. The ileostomy output was dramatically reduced following the introduction of an elemental diet. This case suggests a possible role for the introduction of an elemental diet in the management of high output ileostomies. Besides presenting this case with high output ileostomy, we reviewed the role of ED in other gastrointestinal disorders.

An association between coeliac disease and fertility disorders is well recognised in the current literature, but the information related to non-coeliac gluten sensitivity (NCGS) and infertility is lacking. This case highlights a possible role of treating NCGS in the reversal of infertility.

Individuals with particular genetic backgrounds develop immune responses to wheat proteins and become 'gluten-sensitised'. Mucosal pathology arises through activated mucosal T lymphocytes, resulting in a graded, adverse reaction between particular genes and wheat proteins. Given these varied influences, the Marsh Classification broadly itemises those stages through which a normal mucosa (Marsh 0) evolves in becoming 'flat' (Marsh I, II, III). Recently, Oberhuber and colleagues suggested that Marsh III lesions required subdividing into a, b, c categories. We critically examined these subdivisions by means of correlative light and scanning electron microscopy (SEM). Our results demonstrate that Oberhuber's classification is untenable. In our view deriving from our observations, the artificial subdivisions proposed by those authors actually reflect misinterpretations of the true architectural contours of flat mucosae. Although these workers refer to "villous projections", SEM demonstrates that no such structures are present on flat - or immediately recovering - mucosae. Our data revealed on the surfaces of flat (Marsh III) mucosae, large open "basins", surrounded by raised collars - the latter, when viewed in histological section, being easily misconstrued as "villi". It seems that with subsequent upward growth, these collars coalesce into low ridges, thence becoming broader and higher convolutions. It is noticeable that there are more open spaces on the surfaces of flat mucosae than was appreciated hitherto. We conclude that Oberhuber's revisions of Marsh III into three subcategories (a, b, c), are misinterpretations of the histological appearances of flattened mucosae. Therefore, histopathologists when classifying celiac mucosae, since they add nothing either of diagnostic, nor prognostic, value should resist these subcategories.

Here we describe the second reported case of cannabinoid hyperemesis in UK. A 42 years old patient presented on more than one occasion with vomiting, abdominal pain, fever and dehydration and treated as sepsis with antibiotics. Extensive investigations including upper GI endoscopy, colonoscopy, chest X-ray, abdominal ultrasound, abdominal CT scan, barium swallow and echocardiogram; all reported normal. Once the diagnosis of cannabinoid hyperemesis was established, he was advised to abstain from cannabis use resulting in complete resolution of his symptoms.

Over the last five decades the association between coeliac disease and other autoimmune disorders such as autoimmune thyroid disease or diabetes mellitus type 1 has been well established through many studies and to this day is subject to on-going clinical and scientific investigation worldwide. While no link has been established between celiac disease and type-2 diabetes mellitus, coeliac disease is common in patients with type 1 diabetes. The improvement of symptoms in patients with both conditions through dietary intervention, in the form of a gluten free diet, has been widely described within the literature. Our objectives were to review and synthesise the current knowledge on the nutritional treatment for patients with both conditions.

This evaluation was undertaken to analyse the overall merit of studies for publication in Medical Journals. Peer review, in which peer experts evaluate the value of a manuscript submitted to a professional journal, is regarded as a crucial step in publication. It helps to ensure that published articles describe experiments that focus on important issues and that the research is well designed and executed. By using previous guidelines and literature review, we have developed an assessment tool to evaluate the scientific studies in an effective and systematic order. Using these tools will facilitate comprehensive assessment and will contribute in generating constructive criticisms.

Tolerable gluten thresholds in gluten free products have long been debated together with issues of cross contamination of gluten free cereals during the milling process. It is well established that a totally gluten free diet is virtually impossible owing to the presence of traces of gluten. It is estimated that daily consumption of gluten from contaminated gluten free foods is in the range of 5 to 50 mg. We believe evidence is mounting that it may be possible for some coeliac patients to tolerate gluten above the limits considered permissible at threshold levels. Conversely, it seems there is evidence that some patients might have a much lower threshold for gluten. Whatever would be the individual threshold, GFD may be of benefit to any symptomatic patients even those with milder enteropathy like microscopic enteritis.

Gagne's model of instructional design is based on the information processing model of the mental events that occur when adults are presented with various stimuli and focuses on the learning outcomes and how to arrange specific instructional events to achieve those outcomes. Applying Gagne's nine-step model is an excellent way to ensure an effective and systematic learning program as it gives structure to the lesson plans and a holistic view to the teaching. In this paper, we have chosen a routine practical procedure that junior doctors need to learn: insertion of a peritoneal (ascitic) drain and we use Gagne's "events of instruction" to design a lesson plan for this subject.

Background and aims: the diagnosis of celiac disease requires small bowel biopsies to identify the characteristic mucosal changes. The current biopsy practice among endoscopists for celiac disease is in most part unknown. The aim of this study was to compare the different diagnostic policies in various centers in their current practice. Method: information from a total of 931 confirmed celiac disease patients was retrospectively obtained retrospectively from nine centers in European and Middle Eastern countries. The number of small-bowel biopsies obtained from the duodenal bulb and the second part of the duodenum was compared among different centers. Results: the most frequent stage of mucosal changes amongst Iranian subjects was Marsh IIIa whereas in the rest of the study population was Marsh IIIc. Marsh I and Marsh II were more prevalent in adults (P < 0.05) and Marsh IIIc was significantly higher in pediatric ages between 1 and 15 (P < 0.05). The most common number of biopsy specimens obtained from Romanian subjects was 1 (52% of cases), followed by 2 for Iranian (56%), 3 for Lithuanian (66.7%) and British patients (65%) and 4 for Italian patients (48.3%). For majority of cases, anemia was the most prevalent symptom (18.7%) followed by malabsorption (10.5%), diarrhea (9.3%) and dyspepsia (8.2%), respectively. Conclusions: despite the evidence-based recommendations, this study revealed a poor compliance with major guidelines on diagnosis of celiac disease. We emphasize that taking adequate number of duodenal biopsies should be implemented for an accurate diagnosis and also for the exclusion of celiac disease.

OBJECTIVE: Autoantibodies are used as markers for celiac disease (CD) identifying patients with mucosal lesions. The purpose of this study was to evaluate the sensitivity and role of the autoantibodies such as IgA antiendomysium (EMA), IgA antigliadin (AGA) and the IgA antitissue transglutaminase (tTGA) in histogenesis of celiac disease. METHODS: Seventy-nine cases including 30 untreated celiacs, 5 celiacs on gluten-free diet (GFD), 41 first degree relatives and 3 non-relatives suspected for CD were investigated. Three untreated celiacs with IgA deficiency were excluded from this study group. IgA antibodies to tTGA were determined by ELISA, as described before. Twelve of 41 relatives and 2 cases of non relatives suspected with positive serology underwent a small intestinal biopsy. Results were correlated with the degrees of abnormality of the intestinal mucosa in patients with CD. Intestinal biopsies obtained from study population were evaluated for histological quantification. RESULTS: Celiacs and suspected cases with positive EMA/AGA and or tTGA showed shorter villi (p < 0.007) and/or a higher number of intraepithelial lymphocytes (IEL) (p < 0.035). The sensitivity of serology (EMA, AGA, tTGA) in patients with Marsh IIIc was 100%. However, in patients with Marsh IIIa the sensitivity for EMA, AGA, and tTGA was 40%, 50% and 20% respectively. CONCLUSIONS: The appearance of antibodies is related to the degree of mucosal infiltration by IELs. Although tTGA, like EMA provide a highly sensitive parameter for the detection of celiacs with severe mucosal damage, it appears to be less sensitive (even less than AGA) in celiac patients with milder histopathological abnormalities. However, it should be recognized that the substantial part of the celiac population present with these milder forms of mucosal abnormalities. Using tTGA as a single test in screening may result in missing up to 60-70% of celiacs with mild mucosal abnormalities. Combination with other screening tests (at least with AGA) is essential and strongly recommended