Intraepithelial lymphocyte counts in small intestinal biopsies from children with diarrhoea

We have investigated small intestinal biopsies from children with coeliac disease, acute gastroenteritis, failure to thrive and giardiasis, to find out if a high intraepithelial lymphocyte count is a feature specific to coeliac disease, or whether it is always associated with partial or subtotal villous atrophy. The results indicate that the normal range for childrens' intraepithelial lymphocyte counts is similar to that for adults (around 6-40 lymphocytes per 100 epithelial cells); that counts are high in coeliac disease, but also in some children with giardiasis or with failure to thrive in whom the jejunal biopsy appears otherwise normal; and that intraepithelial lymphocyte counts are normal in acute gastroenteritis even when there is partial villous atrophy with increased lamina propria lymphoid cell infiltrate. Thus, this measurement of small intestinal lymphocyte infiltration may be of diagnostic value is differentiating the diarrhoea of food intolerance from infectious diarrhoeas in young children.     

Intestinal suction biopsy in childhood of experiences during 1968-1975 (author's transl)

From 1968 to 1975 532 intestinal suction biopsies were obtained in 371 children and adolescents using the paediatric Watson capsule. The youngest patient was 2 months old; a 9 months old infant has the lowest body weight of 3 520 g. Mucosal specimens were mainly taken from the upper jejunum. The whole procedure mostly required not more than 30 minutes. No serious complications were seen. Due to technical troubles several attempts were ineffective; the rate of successful biopsies was 89%. The paediatric Watson capsule proved to be easy to handle, mostly reliable, and therefore very suitable for intestinal biopsy in childhood. The dissecting microscope and histological findings were classified into four groups: normal mucosa, slight, moderate and severe mucosal lesions. Severe lesions were almost only demonstrated in patients with coeliac disease: in the active phase, in the early phase of remission under gluten free diet and during gluten loading or normal diet respectively, furthermore in an infant with protracted diarrhoea and in a child with agammaglobulinemia. A flat mucosa is not pathognomonic for coeliac disease but a constant morphological attribute and conclusive for diagnosis. Moderate mucosal lesions were seen in the remission of coeliac disease or during gluten loading and in some cases with protracted diarrhoea of infancy and with chronic malabsorption of unknown origin, furthermore in a child with immunoglobulin deficiency and in another one with iron deficiency anemia. The examination with the dissecting microscope can be performed very easily and makes obvious a very exact diagnostic information which is completed by the histological examination.     

Gluten sensitivity in the rectal mucosa of first-degree relatives of celiac disease patients

BACKGROUND/AIMS: Rectal gluten challenge is a simple, sensitive, and specific test of mucosal gluten sensitivity. Our aims in this study were to evaluate gluten sensitivity in a group of relatives of celiac patients and to compare these findings with those obtained on small bowel histology, celiac disease-related serology, and HLA typing. METHODS: A 4-h rectal gluten challenge was performed with 6 g of crude gluten in saline solution in 29 first-degree relatives, 20 well-diagnosed celiac patients, and 10 subjects in whom celiac disease had been excluded. The number of intraepithelial lymphocytes in pre- and postchallenge frozen rectal biopsies (pan T-cell immunocytochemistry) was quantified by computerized image analysis. RESULTS: The intraepithelial lymphocyte response after gluten instillation was significantly higher in celiac disease patients (median, 126% increase above the baseline count; 95% confidence interval: 61-213%) compared with control subjects (median, -5%; 95% confidence interval: -29-5%). Using a cut-off of 20% change in intraepithelial lymphocyte count, 14 relatives (48%) showed a celiac-like response. Two of these subjects had partial villous atrophy and increased lymphocyte counts in the small bowel mucosa. One of them also exhibited a positive celiac disease-related serology and the typical celiac human lymphocyte antibody (HLA) DQ2. The remaining 12, and all those relatives with a negative challenge, had normal small bowel mucosa and were negative for antigliadin and endomysial antibodies. The characteristic celiac HLA (DQA1 0501 DQB1 0201 heterodimer) was identified in five relatives with positive challenge (including the patient with more severe mucosal atrophy) but was also present in eight relatives with no evidence of gluten sensitivity in the rectal mucosa. CONCLUSIONS: Our study characterizes a subgroup of relatives of celiac patients who show mucosal evidence of sensitization after local instillation of gluten in the rectum but who have no other features of celiac disease.     

Gliadin activates mucosal cell mediated immunity in cultured rectal mucosa from coeliac patients and a subset of their siblings

BACKGROUND: CD3 and gamma delta cells in the rectal mucosa increase after local instillation of gluten in children with coeliac disease and in half of their siblings. Aim- To establish an in vitro system for assessing immunological changes induced by gluten in the rectum. PATIENTS AND METHODS: Rectal biopsy specimens obtained from 13 treated coeliac children, nine of their siblings, and nine controls were cultured in vitro with a peptic-tryptic digest of gliadin or ovalbumin. CD3 and CD25 cells were counted, and the expression of adhesion molecules evaluated. RESULTS: In the lamina propria of coeliac biopsy samples cultured with gliadin, but not in those from controls, the expression of vascular cell adhesion molecule 1 (VCAM-1) was enhanced, and the number of CD25 cells was significantly higher than in those cultured in medium alone; the density of intraepithelial CD3 cells was also significantly higher. No differences were noted in coeliac biopsy specimens cultured with ovalbumin. A discriminant analysis allowed correct classification of all controls and all coeliacs but one, but three of nine siblings were allocated to the coeliac group. CONCLUSIONS: Our data confirm that gliadin is able to activate cell mediated immunity in the rectal mucosa in coeliac patients and in a subset of their first degree relatives.     

Changing clinical features of coeliac disease

The classical clinical picture of coeliac disease includes prolonged diarrhoea with failure to thrive. During the past two decades this type of active presentation of coeliac disease has decreased in many European countries, giving the impression that coeliac disease is a disappearing disease. However, this is not true. The disease can be found in older children with a more or less silent presentation. Silent coeliac disease can be detected by active screening with serological tests. Coeliac disease can be suspected in children suffering from mild gastrointestinal symptoms, such as abdominal pain, and in those with signs of nutritional deficiencies, as well as in children of first-degree relatives of already diagnosed coeliacs, patients with IgA-deficiency, patients suffering from dental enamel hypoplasia or dermatitis herpetiformis, and patients with some other disease known to be associated with coeliac disease, such as diabetes mellitus. According to the fundamental criteria of coeliac disease, the intestinal mucosa is flat when the individual is eating gluten-containing foods. However, this is not strictly true. Intolerance to gluten is obviously variable and the intestinal mucosa may be normal. This type of latent coeliac disease can be detected by analysing genetic markers, measuring antibodies in intestinal fluid or counting the density of intra-epithelial gamma/delta T cells which are increased greatly even in the latent phase of coeliac disease. Thus the general concept of the natural history of coeliac disease is changing.     

Coeliac disease in the adult

Coeliac disease can by defined as a chronic disease characterized by a typical mucosal lesion of the small intestine and an impaired nutrient absorption which improves on withdrawal of gluten from the diet. The prevalence rate has increased over the last decades and just 1/3 of cases are diagnosed in childhood. There is a striking association with class II histocompatibility antigens, HLA-DR3 and HLA-DQ2. Cellular immune response mediated by intraepithelial and lamina propria lymphocytes is the primary event in the small intestine damage. Up to 50% of adult coeliac patients don't present intestinal symptoms being more frequent subclinic forms. The immunological markers of coeliac disease are antigliadin, antireticulin and antiendomysial antibodies, being the last one the most specific. Mortality of coeliac patient is increased mainly for malignancies, being the most frequent the intestinal T lymphoma.     

Production of tubular structures from the aerial mycelium of Actinomyces roseoflavus var. roseofungini]

Jejunal lamina propria plasma cells and eosinophils and intraepithelial lymphocytes were raised in coeliac children on gluten-containing diets, but only intraepithelial lymphocytes were increased in patients on gluten-free diets. In contrast, lamina propria lymphocytes were reduced in children with coeliad disease on gluten-containing diets but were normal in paitents on gluten-free diets. In children with coeliac disease who were studied serially, lamina propria plasma cells and eosinophils and intraepithelial lymphocytes increased, and lamina propria lymphocytes decreased, within three months of the reintroduction of gluten to the diet. These observations are essentially similar to those made in the adult form of the disease and suggest that more than one type of immunological reaction is involved in the pathogenesis of the jejunal lesion.     

Dopamine receptor D2 Ser/Cys311 variant associated with disorganized symptomatology of schizophrenia

AIMS: To investigate the prevalence of lymphocytic gastritis in patients with coeliac disease. METHODS: Gastric biopsies from 70 patients with coeliac disease were examined by light microscopy for the presence of lymphocytic gastritis, defined as 25 or more intraepithelial lymphocytes/100 gastric columnar epithelial cells. RESULTS: Lymphocytic gastritis was found in seven cases. Positive cases had a mean of 32.1 intraepithelial lymphocytes/100 columnar cells, compared with a mean of 13.9 in negative cases, and 5.15 in noncoeliac controls. No differences were found for age, sex, gastric corpus or antrum, or degree of inflammation in the gastric lamina propria. All intraepithelial lymphocytes were of T cell lineage. Cases not showing lymphocytic gastritis did however show significantly increased gastric intraepithelial lymphocytes compared with non-coeliac controls. Eighteen of 70 cases were positive for Helicobacter pylori, and four of seven cases of lymphocytic gastritis were H pylori positive; no significant difference was observed between H pylori positive and negative patients. Three cases had concomitant ulcerative enteritis, of which none showed lymphocytic gastritis, while five cases had concomitant enteropathy associated T cell lymphoma, of which one showed lymphocytic gastritis. CONCLUSIONS: Lymphocytic gastritis occurred in 10% of patients with coeliac disease. Cases without lymphocytic gastritis nevertheless showed increased gastric intraepithelial lymphocytes. Coeliac disease may on occasion be a diffuse lymphocytic enteropathy occurring in response to gluten. Lymphocytic gastritis outside coeliac disease may involve an immune response to luminal antigens, such as H pylori, not unlike the response to gluten in patients with coeliac disease.     

Proposed criteria for diagnosis of celiac disease in children]

At a seminar arranged in September 1997 by the Swedish Paediatric Working Group for Coeliac Disease, a diagnostic protocol proposed by the working group was approved by a majority of the paediatricians present, representing almost all paediatric units in Sweden. Briefly, a small bowel biopsy is called for in all children, both at presentation and as a control during gluten-free dieting. Subsequent gluten challenge and biopsy are mandatory only in cases of atypical presentation or if the diagnosis is questioned at some future date. Serum antigliadin and anti-endomysial antibody tests are complementary tools. Agreement was also reached regarding the institution of a national coeliac disease registry.     

The diagnosis of gluten sensitivity and coeliac disease--the two are not mutually inclusive

The traditional definition of coeliac disease is inadequate because it includes only patients with abnormal small intestinal morphology. Gluten sensitivity is a systemic disorder whose common factor is an immune response to gluten in the context of the susceptible 'coeliac' HLA haplotype and possibly environmental triggers. Gluten sensitivity embraces traditional coeliac disease as well as subjects with normal small bowel morphology including latent coeliac disease, dermatitis herpetiformis, and symptomatic gluten intolerance. The diagnosis of gluten sensitivity and coeliac disease are not mutually inclusive. Small intestinal biopsy and clinical criteria are essential in diagnosing classical coeliac disease. IgA endomysial antibody is valuable in identifying gluten sensitivity and has particular value as a screening test. Serology should include total IgA levels to exclude selective IgA deficiency, a potential cause of false negative IgA endomysial antibody. A combination of histology, serology and clinical criteria will identify most cases of coeliac disease and gluten sensitivity.     

Netherton syndrome revisited

Because coeliac disease often presents atypically it is underdiagnosed. It is suggested that the detection rate may be increased by 12% if serology is used to identify cases of occult enteropathy. All adults noted incidentally to be R1 anti-reticulin antibody (ARA) positive in the course of routine autoantibody testing of 6532 sera over one year were followed. None of the eight patients with seropositive serum was suspected of having coeliac disease. All eight had high titres of IgA anti-gliadin and IgA anti-endomysial antibodies, neither of which is detected in a routine autoantibody test, in addition to IgA R1-ARA. On clinical review coeliac disease was considered probable in only one patient, but because of the strong serological evidence of gluten sensitivity, jejunal biopsy was advised in all eight. Seven agreed and all had villous atrophy and crypt hyperplasia in keeping with coeliac disease. Six of the seven presented initially with vague symptoms such as tiredness or arthralgia. These symptoms disappeared after several weeks of gluten withdrawal. Forty two sera showing reticulin staining patterns other than R1 were used as controls. Low titre IgA anti-gliadin was noted in two of 42 but none had IgA anti-endomysial antibody. These 42 cases were not recommended for biopsy. During our study 58 other new adult cases of coeliac disease were diagnosed, primarily on clinical rather than serological grounds, at the four hospitals that request autoantibody studies. Occult coeliac disease detected serologically thus increased the overall incidence of coeliac disease by 12% from 58 to 65 cases. R1-ARA, even in the absence of the expected symptoms and signs of coeliac disease, is an indication for jejunal biopsy and is a reliable indicator of occult coeliac disease.     

Electrogenic glucose absorption in untreated and treated coeliac disease

Using a method for measuring changes in transmural potential difference across the human jejunum in vivo, the operational kinetic parameters of 'Apparent Km' and PD max for the active electrogenic component of glucose absorption were estimated in a group of healthy volunteers and in patients with coeliac disease. Both the 'Apparent Km' (17+/2mM; mean +/SEM) and the PD max (8.6+/0.7 mV) in nine patients with untreated coeliac disease were significantly lower (p less than 0.005) than in the control group ('Apparent Km' = 74+/5mM; PD max 12.8+/0.9mV, n=20). Treatment of five coeliac patients by gluten withdrawal for less than three months increased significantly the values of both the "Apparent Km (35+/6mM) and the TPD max (11.4+/1.2mV). Treatment of five patients for more than six months caused a further increase in the values of both kinetic parameters ('Apparent Km' = 108+/13mM; PD max =15.6+/2.7mV) to levels which exceeded those in healthy subjects. The possible interpretations of the differences in the kinetic characteristics of electrogenic glucose transport between coeliac patients and healthy subjects are discussed.     

Small intestine in lymphocytic and collagenous colitis: mucosal morphology, permeability, and secretory immunity to gliadin

There is a recognised association between the "microscopic" forms of colitis and coeliac disease. There are a variety of subtle small intestinal changes in patients with "latent" gluten sensitivity, namely high intraepithelial lymphocyte (IEL) counts, abnormal mucosal permeability, and high levels of secretory IgA and IgM antibody to gliadin. These changes have hitherto not been investigated in microscopic colitis. Nine patients (four collagenous, five lymphocytic colitis) with normal villous architecture were studied. Small intestinal biopsies were obtained by Crosby capsule; small intestinal fluid was aspirated via the capsule. IEL counts were expressed per 100 epithelial cells, and intestinal IgA and IgM antigliadin antibody levels were measured by ELISA. Small intestinal permeability was measured by the lactulose:mannitol differential sugar permeability test. IEL counts were normal in all cases, median 17, range 7-30. Intestinal antigliadin antibodies were measured in six cases and were significantly elevated in two patients (both IgA and IgM). Intestinal permeability was measured in eight cases and was abnormal in two and borderline in one. These abnormalities did not overlap: four of nine patients had evidence of abnormal small intestinal function. Subclinical small intestinal disease is common in the two main forms of microscopic colitis.     

Coeliac disease: frequent occurrence after clinical onset of insulin-dependent diabetes mellitus. Childhood Diabetes in Finland Study Group

Coeliac disease was searched for in a series of 776 children with newly diagnosed IDDM. During the follow-up of 2 to 3 years from diagnosis, reticulin and gliadin antibodies were measured, and a jejunal biopsy was performed in those cases with high levels of antibodies; 19 children were identified with coeliac disease, giving the prevalence of 2.4%. In only one case had coeliac disease been diagnosed before IDDM. Nine patients with proven coeliac disease were negative for antibodies when IDDM was diagnosed, but became positive within 24 months. All patients found to have coeliac disease were positive for IgA reticulin antibodies, but only 12 of 18 (67%) showed a high level of IgA gliadin antibodies. Of the 18 patients genotyped for HLA DR locus, 14 (78%) were positive for DR3 and 10 (56%) were positive for DR4. DQB1*0201 allele was present in 17 of 18 patients (94%). Coeliac disease in children with IDDM tends to develop soon after diabetes is diagnosed. Routine screening for coeliac disease is recommended repeatedly during the first years after the diagnosis of IDDM.     

Blood xylose as a screening test for malabsorption in jejunal mucosa abnormalities; importance of diet in interpretation

Blood xylose level 60 min. after an oral dose of 10 g/m2 xylose was compared with the histology of the jejunal mucosa in 56 children. Ninety-two percent of children with blood xylose below 20 mg/100 ml had an abnormal jejunal mucosa; 98% of children with a normal mucosa had a blood xylose above 20 mg/100 ml. In children with coeliac disease the following observations were made: 1) blood xylose was above 20 mg/100 ml in 50% of children with flat mucosa; all were given a diet excluding gluten; 2) blood xylose levels which were initially below 20 mg/100 ml were found above this level 3 to 12 days after the onset of the diet; 3) all the histological relapses following re-introduction of gluten in the diet were not associated with a decrease of blood xylose level below 20 mg/100 ml.     

The eosinophilic response of the rat to infection with Taenia taeniaeformis

Rats were dosed with eggs of Taenia taeniaeformis and hematologic parameters were measured throughout the course of primary infection. There was no evidence of anemia but differential leukocyte counts revealed distinct and reproducible patterns of white blood cell changes. A lymphocytosis developed at the end of the 1st and 5th weeks postinfection (p.i.). Neutrophil counts peaked 8 days p.i., although at that time there was no marked neutrophilic infiltration of the tissues. Eosinophil counts began to rise during the 2nd week p.i., and reached a peak during the 3rd week, followed by a decline and then another peak during the 5th week p.i. Eosinophilic infiltration of the tissues was remarkable during the period of peripheral eosinophilia. A wide zone of eosinophils surrounded the developing larvae at 22 days p.i. and persisted in some cases for a further 2 weeks. Eosinophils remained in lesser numbers in the connective tissue capsule throughout the infection, often in association with plasma cells. After oral challenge with 1,000 eggs infected rats showed brisk secondary eosinophilic responses 3 to 7 days later but other hematologic parameters were unaffected. Average peripheral eosinophil counts at 3 and 4 days post-challenge were significantly higher than those in unchallenged controls (P less than 0.05 and P less than 0.01, respectively). There was no detectable increase in eosinophilic infiltration of small intestinal tissues in challenged rats. These results are discussed in relation to current understanding of the mechanisms of eosinophil chemotaxis in vitro and the possible causes of local eosinophil accumulation in parasitic infections in vivo.     

Is an intestinal permeability test a valid marker for slight dietary transgressions in adolescents with coeliac disease?

Adolescents with coeliac disease often fail to adhere to a strict gluten free diet. The effectiveness of intestinal permeability to sugars as a marker of slight dietary transgressions by such adolescents was assessed. Severe dietary transgressions were excluded from the study. Subjects were divided into two groups according to whether they committed slight dietary transgressions or adhered to a strict gluten free diet. A reference group of preadolescents with coeliac disease was also included in the study. Intestinal permeability and antigliadin antibody tests were performed on all patients. The diagnostic marker of intestinal permeability was excellent in the reference group. Neither the intestinal permeability test nor antigliadin antibody tests, however, succeeded in discriminating between the two groups of adolescents considered in this study. In conclusion the intestinal permeability test is not a valid marker for slight dietary transgression in such patients.     

Coeliac disease

In coeliac disease there is an abnormality of the intestinal mucosa which is caused by ingesting gluten. The intestinal lesion affects predominantly the proximal small intestine and the ileum is either normal or less severely involved than the jejunum. In some cases adaptive changes occur in the ileum, producing enhanced absorption in that region when there is malabsorption in the jejunum. The characteristic absorptive abnormality in coeliac disease is therefore jejunal malabsorption and ileal hyperabsorption. When such a situitation develops it is possible that an indivisual with a flat jejunal mucosa may develop no symptoms of the disease, since the adaptive changes in the ileum compensate for the jejunal lesion. This may explain why in Western society there are probably more cases of coeliac disease undiagnosed in the community that have been treated by their doctors. The basic lesion in coeliac disease appears to be genetically determined and it is likely to be a failure to clear antigen which normally enters the lamina propria of the gut resulting in the formation of immune complexes with complement fixation at gut level.     

Immunocytochemistry of mucosal changes in patients infected with the intestinal nematode Strongyloides stercoralis

AIM: To investigate the immunopathological changes in duodenal tissues induced by strongyloidiasis and to relate these to degrees of clinical severity. METHODS: Tissues taken from 21 patients showing mild, moderate or severe symptoms of strongyloidiasis, and from non-infected controls, were sectioned and stained immunocytochemically for IgA, secretory component (SC) and HLA-DR. Immunopathology was assessed by changes in numbers, intensity and distribution of stained cells. RESULTS: Parasitised individuals showed villous atrophy and crypt hyperplasia. There was notable infiltration of the lamina propria by IgA positive plasma cells and of the epithelium by intraepithelial lymphocytes. Infection was also associated with increased expression of SC and decreased expression of HLA-DR in epithelial cells. Changes in all parameters correlated with degree of clinical severity. CONCLUSIONS: Profound mucosal changes are induced by strongyloidiasis. Some are analogous to those seen in coeliac disease, but others seem quite unusual. It is likely that these changes are functionally related to the immunopathophysiological consequences of infection seen in patients with severe disease.