1	Early Diagnosis of Gluten Sensitivity Using Fecal Testing: Report of an 8-year study Kenneth Fine, M.D. Intestinal Health Institute Dallas, TX
2	Aretaeus the Cappadocian 100 A.D.
3	Aretaeus the Cappadocian “On the Coeliac Affection” Symptoms/Signs “Patients have eructations, flatulence and heavy pains of the stomach” “They are emaciated and atrophied, pale, feeble, incapable of performing any of their accustomed work” “The stomach labors in digestion when diarrhea, consisting of undigested food in a fluid state, seizes the patient”
4	Dr. Samuel Gee 1888 “On the Coeliac Affection” “Errors in diet may perhaps be a cause..... to regulate the food is the main part of treatment” “The allowance of farinaceous food must be small; highly starchy food, rice, sago, corn flour are unfit” “Malted food is better, also rusks or bread cut thin and well toasted on both sides”
5	Dr. Willem Karel Dicke
6	Conclusions of Dr. Dicke’s Doctoral Thesis Celiac disease is caused by the harmful effects of wheat, barley, rye, and oat flour It is gliadin, an alcohol soluble subfraction of gluten, that is the deleterious factor (not starch) Following removal of gluten from the diet, there is a time lag before symptoms disappear, or reappear with its re-introduction
7	Celiac Sprue Traditional Definition Symptoms or signs due to malabsorption of fluid, electrolytes, and/or nutrients Small intestinal histopathology Inflammation of lamina propria Intraepithelial lymphocytosis Villous atrophy Crypt hyperplasia Clinical improvement with gluten-free diet
8	Celiac Sprue - Signs, Symptoms, Associated Diseases Abdominal - diarrhea, gas, bloating, nausea, vomiting, fat in stool, constipation Musculoskeletal - weakness, muscle spasms, bone pain, numbness, osteoporosis, low calcium Blood - anemia, high platelets, low clotting factors Associated diseases - autoimmune, microscopic colitis, Crohn’s disease, low pancreatic enzymes, dermatitis herpetiformis, lymphoma, cancer
9	Celiac Sprue Clinicopathologic Spectrum Clinical presentation Asymptomatic (with or without iron deficiency) Abdominal bloating, nausea, G-E reflux Diarrhea, weight loss, symptoms of fat malabsorption Histopathology Mild intraepithelial lymphocytosis or plasmacytosis of LP, normal villi and crypts (May be read as normal) Partial or subtotal villous atrophy and inflammation Total villous atrophy, inflammation, crypt hyperplasia
10	Normal Small Intestinal Histology
11	Celiac pathology
12	Celiac Endoscopic Abnormalities
13	Celiac Sprue- Evolution of Diagnostic Tests Ancient times - clinical observation 1950-1960’s - response to gluten free diet, 72-hr fecal fat, low xylose test, origins of SB biopsy 1970’s - Anti-gluten Ab in blood / intestinal fluid 1980’s - Antigliadin / antiendomysial Ab in blood 1990’s - Antitissue transglutaminse Ab Mistakenly thought to rule in and rule out all disease
14	Common Misconceptions About Gluten Sensitivity/Celiac Sprue Patients cannot have gluten sensitivity/celiac sprue: If they have not lost weight If they are obese If they have no intestinal symptoms If they are elderly If they have negative screening blood tests If they have no steatorrhea If they have a normal small bowel biopsy
15	CS is “Tip of the Iceberg” of Gluten-Induced Disease Celiac sprue is the end-stage of immunologic gluten sensitivity directed at the small intestine HLA genes (HLA-DQ2, DQ8) direct gluten-induced damage to SB; other HLA/non-HLA genes damage skin (e.g. DH and/or other organs Blood tests/biopsies can only diagnose celiac sprue GS with mild/no SB damage; autoimmune disease of other organs; relatives of celiacs are being missed
16	Studies of Gluten-Sensitivity without Villous Atrophy “Gluten-Sensitive Diarrhea” (Gastroenterology 1980;79:801) 8 females, severe chronic diarrhea,normal blood and stool tests “Gluten-Sensitivity with Mild Enteropathy” (Gastro 1996;111:608) 10 pts. diarrhea/steatorrhea, anemia, osteoporosis, mouth ulcers Small bowel biopsies reacted immunologically to gluten in vitro “Celiac-like Abnormalities in IBS patients” (Gastro 2001;121:1329) Small intestinal antigliadin IgA Ab, HLA-DQ2 in 30% of IBS pts “Celiac Disease without Villous Atrophy” (Dig Dis Sci 2001;46:879) 10 pts. with abdominal symptoms, osteoporosis, (-* IEL’s All pts. became well on GFD; recurred with gluten
17	Shortcomings of Celiac Blood Tests Two research groups tested 69 or 89 untreated celiacs, and 16 first degree relatives Serum antigliadin and antiendomysial IgA antibody Each test positive in only 59% of celiacs One or the other test positive in only 76-78% Positivity dependent on degree of villous atrophy (VA) Partial VA - 31% Subtotal VA - 70% Total VA - 100% Relatives - mild SB inflammation; all tests negative
18	Duration of Gluten Consumption and Risk of Autoimmune Disease
19	Main Autoimmune Diseases Associated with Celiac Sprue Diabetes mellitus, type 1 Dermatitis herpetiformis Alopecia Sjogren’s syndrome, rheumatoid arthritis, others Thyroiditis Autoimmune hepatitis, PBC Psoriasis Microscopic colitis
20	Microscopic Colitis Syndrome Chronic, watery, non-bloody diarrhea Normal/near normal colonoscopy May have patchy edema, loss of vascularity, erythema, occasional mucosal fracture Abnormal colonic biopsy Lamina propria inflammation Intraepithelial lymphocytosis Surface epithelial flattening +/- thick subepithelial collagen band
21	Microscopic Colitis
22	Celiac-Like Genes and Mild Enteropathy in MC 64% have DQ2; most remainder have DQ1,3 70% have mild SB enteropathy but rarely CS No more antigliadin antibody in serum than general population Histopathology of MC in colon identical to celiac sprue in small intestine
23	Antigliadin Ab In the Intestine but not Blood with Mild Intestinal Damage Researchers assessed blood and aspirated small bowel fluid for antigliadin IgA antibody in: Celiacs; blood and SB aspirate was positive Normals; blood and SB aspirate was negative Celiacs after 1 yr on GFD; blood was negative, intestine was positive when mild SB inflammation persisted Used intestinal lavage and analysis of rectal effluent to test for the presence of intestinal antigliadin Ab Called “a relatively non-invasive screening method for early celiac sprue”
24	Fecal Analysis: Measures Intestinal Antigliadin Ab Simply
25	The Founding of EnteroLab.com and IHI Offered access to fecal testing for gluten/food sensitivity, malabsorption, colitis to the public and medical practitioners on the Internet Tracked clinical information, results of tests Followed up by online survey Aim: to bring the benefits of medical research to the public while ongoing research, and public/medical education are underway (years)
26	Negative Control Groups
27	Clinical Background Of Test Clientele (n=7336) 42% have autoimmune disease 21% have IBS symptoms 20% have family history of celiac/GS 6% have microscopic colitis 2% have chronic fatigue 8% have wt. loss, headaches, allergies, seizures, osteoporosis, neuropathy, autism, ADD/ADHD Only 0.6% have no symptoms or identified risk
28	Overall Results Of Test Clientele 99.4% Sick/Symtpomatic 57% have HLA-DQ2 or DQ8 (celiac genes) 42% in general U.S. population Only 0.07% have no predisposing gene 0.4% of general U.S. population 60% positive for gluten sensitivity Highest gliadin values (>200) with DQ2,8,7 in 88% 60% in general U.S. population
29	Prevalence of Gluten Sensitivity in Various Groups
30	Symptoms >1 Yr Follow-Up
31	“Improved Health” Follow-Up
32	“Overall Health” Follow-Up
33	Published Studies of Others Fecal Gliadin Testing First report, a letter from France 1994 (Clin Lab) 10 patients with CS had detectable AGA in stool 2 did not have it in serum 2002, Italian study showing AGA and AEA in 21 CS patients, 10 treated CS after challenge (Am J Gastro) “Proved intestinal mucosa produces Ab” Did correlates of biopsies reacting to gliadin in vivo
34	Other Studies of Fecal Gliadin Testing (cont.) 2004 German Study found higher fecal AGA in 26 CS than 167 healthy controls (Clin Lab) 2006 German Study of 20 celiac kids (BMJ) Did not alter serum method or calculation of positive 10% sensitive, 98% specific If used a lower cut off, was 82% sensitive, 58% specific Only applied to CS, not gluten sensitivity
35	Factors to Consider When Applying Serum Method to Stool Amount sample is diluted prior to analysis Technique/amount of washing of ELISA plates Greater solid contaminant of fecal fluid vs. serum Mathematical conversion of OD to a Unit How calculated Unit is interpreted: norm vs. abnorm Centrifuge speed for stool (too high neg result) Proper collection and preservation of stool
36	Research Supporting Non-Celiac Gluten Sensitive Genes DQ1,3 found more commonly in MC and RA DQ3 subtypes are: DQ7, DQ8, DQ9 DQ1 found more commonly in gluten ataxia DQ9 binds and reacts to gluten in vitro Only DQ4 seems not to increase risk of GS Rare in U.S. - 13% heterozygous, 0.4% homo.
37	Evolution of Screening Tests for GS/Celiac Sprue 100 A.D. - 1950 - clinical observation 1950 -1960’s - response to gluten free diet, 72-hr fecal fat, oral xylose test, origins of SB biopsy 1980 -1990’s - serologic testing for antigliadin Ab, antiendomysial Ab, antitissue transglutaminase Ab 2000’s - fecal testing for Antigliadin Ab and Antitissue transglutaminase Ab^†; Quantitative fecal fat microscopy for malabsorption^†; HLA-DQ typing
38	Quantitative Fecal Fat Microscopy * New method of fecal fat microscopy allowing quantitation of fecal fat output from a single stool Easily diagnoses intestinal nutrient malabsorption and establishes a numeric pretreatment baseline Correlates with quantitative fecal fat excretion measured in 72-hour stool collections More sensitive than qualitative fecal fat & 72-hour collections (30-50% do not collect all stools)
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40	EnteroLab.com Approach to Intestinal/Overall Health Stool for Antibody and Malabsorption Testing Fecal antigliadin and antitissue transglutaminase IgA Quantitative fecal fat microscopy Swab of inside of mouth for Gene Testing HLA-DQB1 typing for gluten sensitive/celiac genes Other tests available: Fecal anti-casein, anti-ovalbumin, anti-Saccharomyces cerevisiae, anti-soy IgA for dietary milk, egg, yeast and soy sensitivity; fecal lactoferrin for acute or chronic colitis; extensive food sensitivity panel coming soon
41	Who Should Be Screened? Microscopic colitis, Crohn’s, UC, any IBD Relatives of gluten-sensitive individuals Chronic diarrhea of unknown origin Irritable bowel syndrome Inflammatory bowel disease Gastroesophageal reflux disease Hepatitis C, Autoimmune/other liver disease Short stature in children, Down's syndrome
42	Who Should Be Screened? Female infertility, mother of spina bifida Peripheral neuropathy,Seizure disorders Psychiatric Dz, Depression, Autism Diabetes mellitus, type 1, type 2 (?) Rheumatoid arthritis, Sjogren's syndrome, Lupus, Autoimmune thyroid disease, Any autoimmune Dz Asthma, AIDS, Osteoporosis, Iron deficiency Everyone!
43	Microscopic Colitis Recommended Treatment Stop NSAID’s (including aspirin), anti-acid Rx Fecal fat test Fecal AGA IgA; ATTA IgA GFD if positive or as trial Lactobacillus GG 1 BID-TID No response – wash out gut, cholestyramine, stop estrogen, BSS Bismuth subsalicylate tablets 3 tid for 8 weeks
44	Mechanisms of Public Service Intestinal Health Institute (not-for-profit institute) Medical research, education, public service http://www.intestinalhealth.org FinerHealth and Nutrition Free online educational information http://www.finerhealth.com EnteroLab.com Breakthrough diagnostic testing available, affordable http://www.enterolab.com The Organic Alternative.com (coming soon) Affordable organic dried fruit, nuts, health products http://www.theorganicalternative.com