Sorbitol H2-breath test versus anti-endomysium antibodies to assess histological recovery after gluten-free diet in coeliac disease

Background. Gluten-free diet plays a key role in treatment of coeliac disease, but it is difficult to evaluate its effect on improvement of villous architecture using sensitive non-invasive tests.Aims. To compare sorbitol H₂-Breath Test with antiendomysial antibodies in the follow-up of coeliac disease to detect histological recovery.Methods. A total of 38 consecutive patients with coeliac disease were studied. All underwent Sorbitol H₂-Breath Test, antiendomysial and oesophagogastroduodenoscopy with multiple bioptic samples before diet and then 6, 12 and 18 months after gluten-free diet. Expiratory samples were collected before patients drank the test solution (5 g sorbitol in 150 ml tap water) and thereafter every 30 min for 4 hours. An increase in H₂ concentration of ≥20 ppm, above fasting baseline was considered positive for sorbitol malabsorption. Antiendomysial antibodies were evaluated by the indirect immunofluorescent method.Results. Antiendomysial antibodies were positive in 32/38 patients before gluten-free diet (84.21%), while they were positive in 20/34 (54.82%), 2/16 (12.5916) and 0/2 (0%) cases after 6, 12 and 18 months of gluten-free diet, respectively, no correlation being found with improvement of histological lesions (p=ns). As far as concerns sorbitol H₂-Breath Test, maximal cut-off value (in ppm) decreased progressively and parallel to histological recovery during follow-up. Indeed, it decreased from a mean 63 ppm before diet to 35, 19 and 12 ppm, after 6, 12 and 18 months of gluten-free diet, with a statistical difference being found before and after [p<0.001]. Likewise, the peak value (in minutes) appeared progressively later during follow-up, parallel to histological recovery. In fact, it appeared at a mean of 119 minutes before gluten-free diet, while it appears at a mean of 164, 195 and 219 minutes after 6, 12 and 18 months on glutenfree diet. A statistical difference before and after start of gluten-free diet was found also in this case (p<0.001). Conclusions. Sorbitol H2-Breath Test is better than antiendomysial antibodies in revealing histological recovery in the follow-up of coeliac patients after the start of gluten-free diet due to its good correlation with histological damage. Moreover, it also appears to be able to detect dietary mistakes of the patients on gluten-free diet.     

Usefulness of the organ culture system in the in vitro diagnosis of coeliac disease: a multicentre study

OBJECTIVE: Diagnosis of coeliac disease is based on the presence of villous atrophy which recovers following a gluten-free diet. The presence of circulating antiendomysial antibodies as well as their disappearance after a gluten-free diet supports the diagnosis. It has also been demonstrated that antiendomysial antibodies are detectable in supernatants of cultured intestinal biopsies from patients with coeliac disease. The objective of this study was to compare the histology and antiendomysial antibodies in culture supernatants of intestinal biopsies to validate the in vitro organ culture system as a future diagnostic tool for coeliac disease. MATERIAL AND METHODS: Seventy-five antiendomysial serum-positive patients on a gluten-containing diet were evaluated. Patients underwent endoscopy with 5 biopsy fragments: 3 for histology, 1 cultured with and the other without gliadin-peptide activator. Antiendomysial antibodies were evaluated in all culture supernatants. RESULTS: Sixty-eight patients had evidence of villous atrophy, while 73 out of 75 were positive to the organ culture system. The agreement rate between organ culture and histology results was 94%. CONCLUSIONS: As all the centres participating in the study obtained good agreement between organ culture and histology results, the new system could be considered a reliable tool for the diagnosis of coeliac disease. Nevertheless, it is possible to highlight cases with an organ culture-positive and -negative histology. This feature could be of considerable interest because, as the sensitivity of organ culture seems to be greater than the initial histology, the new system might be useful in uncertain cases where the risk of missing the diagnosis of coeliac disease is high.     

IgA-class transglutaminase antibodies in evaluating the efficacy of gluten-free diet in coeliac disease

OBJECTIVE : Serum IgA-class tissue transglutaminase antibody has proved effective in screening for coeliac disease. The response to a gluten-free diet has been assessed on the basis of small-intestinal morphology. We investigated whether the tissue transglutaminase antibody test could substitute biopsy in this respect, and whether the test is better than the endomysial antibody test in follow-up. DESIGN : Controlled cross sectional, and follow-up study. METHODS : Serum IgA-class tissue transglutaminase antibodies and endomysial antibodies were determined in 87 coeliac adults on a gluten-free diet. All underwent small bowel biopsy, and the mucosal morphology was interpreted along with Marsh's grading 0-3. In 30 patients histological and serological data could be analysed before and after adopting the diet; Marsh 3 was considered inadequate mucosal recovery during the diet. RESULTS : Of the 87 coeliac patients 27 showed Marsh 3 villous atrophy on gluten-free diet; of these 27, tissue transglutaminase antibody was within normal limits in 16 (59%) and endomysial antibody in 20 (74%). Two (7%) out of 29 with normal mucosa (Marsh 0) had positive tissue transglutaminase antibodies. Six (55%) out of 11 admitting regular dietary lapses remained tissue transglutaminase antibody negative. In the follow-up, serum IgA-class tissue transglutaminase antibody was initially positive in 28 (93%) out of 30 untreated patients; even a significant decrease in tissue transglutaminase antibody did not guarantee mucosal recovery. CONCLUSIONS : A substantial number of coeliac patients with negative tissue transglutaminase or endomysial antibodies may still have manifest mucosal villous atrophy. Small bowel biopsy is therefore still necessary to ensure that the gluten-free diet is adequate.     

Schizophrenic symptoms and SPECT abnormalities in a coeliac patient: regression after a gluten-free diet

De Santis A, Addolorato G, Romito A, Caputo S, Giordano A, Gambassi G, Taranto C, Manna R, Gasbarrini G (Catholic University, Rome, Italy). Schizophrenic symptoms and SPECT abnormalities in a coeliac patient: regression after a gluten-free diet (Case Report). J Intern Med 1997; 242 : 421–23.
A 33-year-old patient, with pre-existing diagnosis of 'schizophrenic' disorder, came to our observation for severe diarrhoea and weight loss. Use of single photon emission computed tomography, (^99mTc)HMPAO SPECT, demonstrated hypoperfusion of the left frontal brain area, without evidence of structural cerebral abnormalities. Jejunal biopsy showed villous atrophy. Antiendomysial antibodies were present. A gluten-free diet was started, resulting in a disappearence of psychiatric symptoms, and normalization of histological duodenal findings and of (^99mTc)HMPAO SPECT pattern. This is the first case in which, in an undiagnosed and untreated coeliac patient with psychiatric manifestations, the (^99mTc)HMPAO SPECT demonstrated a dysfunction of frontal cortex disappearing after a gluten-free diet.     

Assessment of autonomic function in untreated adult coeliac disease

AIM: Some recent studies showed that alteration of upper-gut motility in coeliac disease may be related to dysfunction of autonomic nervous system. The aim of our study was to investigate whether autonomic nervous system was altered in untreated and unselected coeliac disease patients. METHODS: We studied 8 untreated and consecutive coeliac disease patients (2 males and 6 females, age range 37+/-14.5 years). Histological evaluation of duodenal mucosa, anti-gliadin antibodies (AGA), antiendomysial antibodies (EMA) and anti-tTG antibodies and sorbitol H2 breath test were performed in all patients. Extrinsic autonomic neuropathy was assessed by the standardized measurement of cardiovascular reflexes (lying-to-standing, Valsalva manoeuvre, deep breathing, sustained handgrip). The results obtained were compared with a healthy, asymptomatic control group (6 males and 7 females, age range 42.3+/-13.5 years). RESULTS: Coeliac patients exhibited a lower increase of PAS as a response to isometric effort, a reduction of spectral power LF as a response to clinostatic position, but without statistical significance. Also they showed a lower tolerance to orthostatic position, associated with a latent disequilibrium of sympathetic-vagal balance, a relative prevalence of parasympathetic component of the autonomic function. However, these results were not statistically significant when compared with control group (P = n.s.). And they were unchanged after 6 and 12 mo of gluten-free diet. CONCLUSION: This study failed to confirm a significant correlation between autonomic dysfunction and coeliac disease, yet we could not exclude a role of autonomic dysfunction in the genesis of systemic symptoms in some coeliacs.     

Growth hormone deficiency and coeliac disease: an unusual association?

OBJECTIVE: To assess the occurrence of growth hormone deficiency (GHD) in patients with coeliac disease (CD). STUDY DESIGN: A total of 1066 children diagnosed elsewhere with short stature were referred to our centre for second-line evaluation in a 6-year period. All patients were screened for CD by antiendomysial antibodies (EMA) and those with positive sera underwent intestinal biopsy. RESULTS: Among the 1066 short children, 210 (19.7%) had GHD and 12 (1.12%; chronological age from 3.6 to 12.3 years, bone age from 1.5 to 10.5 years, SDS height from -3.05 to -0.48), having positive EMA, showed histologically confirmed CD. Nine of these latter 12 CD children had a beneficial effect on growth rate after the first year of gluten-free diet, while the remaining three showed no catch-up growth. A careful endocrinological investigation in these three CD boys showed an isolated GHD in two cases and a multiple GHD in one case. The congenital origin of GHD is supported by the congenital abnormalities documented by magnetic resonance imaging. GH therapy associated with gluten-free diet led to an increased growth rate. CONCLUSION: GH secretion should be evaluated in coeliac patients showing no catch-up growth after a period on a gluten-free diet in spite of reversion to seronegativity for EMA. In the case of GHD and CD, replacement GH therapy should be started during a gluten-free diet.     

Resurrection of gliadin antibodies in coeliac disease. Deamidated gliadin peptide antibody test provides additional diagnostic benefit

OBJECTIVE: Circulating antibodies against naive, whole gliadin have been replaced by more accurate endomysial and tissue transglutaminase antibody tests in the diagnosis of coeliac disease. The purpose of this study was to compare these serological tests with a new test recognizing antibodies against deamidated and defined gliadin peptides. MATERIAL AND METHODS: The study population comprised selected coeliac disease patients in a tertiary clinic: newly detected patients before and after a gluten-free diet, patients with persistent small-bowel mucosal villous atrophy despite a strict gluten-free diet and non-coeliac controls reporting abdominal symptoms after ingestion of cereals. Comparisons were made between serum IgA-class gliadin peptide, endomysial, tissue transglutaminase and conventional gliadin antibodies. RESULTS: The deamidated gliadin peptide antibody test showed a sensitivity of 91% and a specificity of 98% in coeliac disease. The tissue transglutaminase antibody test performed equally well. The specificity of endomysial antibody was just as high, but its sensitivity was lower, 80%. The conventional gliadin antibody test showed poor sensitivity and specificity. Combination of the deamidated gliadin peptide and tissue transglutaminase tests offered the best sensitivity without loss of specificity in the diagnosis of coeliac disease. All antibody levels declined in line with mucosal recovery. The deamidated gliadin peptide antibody test showed six of the nine cases with small-bowel mucosal damage persisting on a gluten-free diet, whereas tissue transglutaminase detected only two cases and endomysial antibody none. CONCLUSIONS: The new gliadin peptide antibody test proved highly accurate in the diagnostic work-up and follow-up of coeliac disease and can be endorsed in combination with the tissue transglutaminase test.     

Effect of an elemental diet (Vivonex) on the absorption abnormalities and histological appearances of the jejunum in untreated adult coeliac disease.

The effect of an elemental diet (Vivonex) together with a gluten-free diet on the absorption of water, sodium and chloride in the jejunum was studied in 4 patients with untreated adult coeliac disease before and after a 1-month course of therapy. The morphology of the jejunum was also studied by jejunal biopsy taken at the same time as the intestinal perfusion. The results were compared with those obtained in 4 patients with adult coeliac disease treated with a gluten-free diet alone. No marked improvement was noted in the transportation of water, sodium and chloride after either treatment with Vivonex and a gluten-free diet or after a gluten-free diet alone, and no marked histological changes were found. Clinical improvement occurred in both groups of patients, in that the diarrhoea improved in all patients and they generally felt better. There appears to be no additional advantage of using an elemental diet with a gluten-free diet in the initial management of adult coeliac disease.     

Sorbitol malabsorption in normal volunteers and in patients with coeliac disease.

Sorbitol is a hexahydroxy alcohol used as a sugar substitute in many dietetic foods and as a drug vehicle. Previous studies have suggested that sorbitol ingestion may be an additional cause of non-specific gastrointestinal distress. We evaluated sorbitol malabsorption in 30 healthy volunteers, seven patients with untreated coeliac disease and nine patients with coeliac disease on a gluten free diet, using a four hour H2 breath test. After ingestion of test solutions containing sorbitol 10 and 20 g and of four sweets (6.8 g sorbitol), 90%, 100%, and 62% of healthy volunteers, respectively had significantly raised H2 excretion, indicating malabsorption of sorbitol. Of all healthy subjects tested, 45% after 10 g, 100% after 20 g, and 50% after four sweets complained of symptoms of carbohydrate intolerance during the eight hours after sorbitol. After a 5 g dose given at concentrations of 2%, 4%, 8%, 16%, malabsorption was shown in 10%, 12%, 22%, and 43% of the healthy volunteers. Symptoms of intolerance at 5 g were experienced only at concentrations of 8% and 16%. Unlike healthy volunteers and coeliac patients on a gluten free diet, 100% of untreated coeliacs malabsorbed a 2% solution of 5 g sorbitol. These results show that malabsorption and intolerance of sorbitol may result from ingestion of doses and/or concentrations usually found in many foods and drugs; they underline the need to consider this as a possible and hitherto underestimated cause of gastrointestinal symptoms.     

Antiendomysial and antitissue transglutaminase antibodies in gluten-induced enteropathy

Although the gold standard for diagnosis of coeliac disease remains the small bowel biopsy, the broad spectrum and the non-specific nature of many of the clinical manifestations makes biopsy as the initial investigation impossible. So, much effort has been put into the identification of serological screening tests with adequate sensitivity and specificity. The aim of this study was to identify antiendomysial and antitissue-transglutaminase antibodies as serum markers of coeliac disease in a group of patients admitted in the 3rd Medical Clinic, 4th Medical Clinic and 1st Pediatric Clinic as well as in the general population. The study was made on serum samples collected from 64 persons, adults and children with or without documented coeliac disease. Antitissue transglutaminase (anti-tTG) antibodies were determined by the sandwich ELISA technique, using a commercial kit. Antiendomysium (EMA) antibodies were dosed by indirect immunofluorescence. Twenty-four subjects were positive for IgA anti-tTG and 23 for EMA. We found that IgA anti-tTG were 100% positive in patients with clinical suspicion of coeliac disease, the diagnosis being confirmed by biopsy. All, but two patients on a gluten-free diet had small or zero EMA levels. We also found that serum EMA levels correlated perfectly with the degree of histological alterations. A very good correlation was found between the serum concentrations of the two antibodies studied     

Effect of gluten-free diet on splenic hypofunction of adult coeliac disease.

Splenic function has been serially measured by counting pitted red cells in 15 coeliac patients, before and during a gluten-free diet. The basal percentage values of pitted cells decreased significantly during treatment but no correlation was observed between the duration of the gluten-free diet and the percentage of recovery of splenic function over basal values. Out of six coeliacs with pitted cell values consistent with splenic hypofunction, three showed a total recovery after gluten withdrawal. Our data suggest that, contrary to recent reports, hyposplenism in adult coeliac disease is improved by a gluten-free diet, and that environmental factors may be important in determining and maintaining this complication.     

Coeliac Disease: Histopathological Findings in the Small Intestinal Mucosa Studied by a Peroral Biopsy Technique

Villous atrophy, changes in the surface epithelium, mucosal thickening, and glandular hypertrophy were a feature of all the mucosal biopsies from the small intestine obtained from eight coeliac children. No histological differences were observed between the children previously treated with intermittent gluten-free diets and the untreated children. Serial biopsy studies were carried out on one coeliac child before and after treatment with a gluten-free diet over a period of two years. On the whole they confirmed the irreversible nature of the observed histopathological changes but minor improvements could not be excluded. Mucosal abnormalities in coeliac disease are the same as in adult idiopathic steatorrhoea, where they are observed in patients with or without a response to a gluten-free diet. It is concluded that the elimination of gluten from the diet has little if any influence on the histopathological abnormalities observed in coeliac disease.     

Anti-ganglioside antibodies in coeliac disease with neurological disorders

BACKGROUND: Anti-ganglioside antibodies have been described in sera of coeliac patients with peripheral neuropathy and cerebellar ataxia. AIMS: To investigate the correlation between anti-ganglioside antibodies and neurological involvement in coeliac disease before and after gluten-free diet. PATIENTS AND METHODS: Twenty-two untreated coeliac patients with neurological dysfunction and 30 untreated coeliacs without neurological dysfunction, 20 patients with neurological disorders, 50 autoimmune disease and 20 blood donors were tested for anti-GM1, anti-GD1b and anti-GQ1b IgG and IgM antibodies by enzyme-linked immunosorbent assay. RESULTS: IgG antibodies to at least one of the three antigens tested were positive in 64% of coeliac patients with neurological symptoms compared to 30% of coeliacs without neurological dysfunction (P=0.02), 50% of patients with neurological disorders (P=ns), 20% with autoimmune diseases (P=0.003) and none of blood donors (P=0.0001). A strict gluten-free diet determined anti-ganglioside antibody disappearance in about half of coeliacs. CONCLUSIONS: A significant correlation between anti-ganglioside antibodies and neurological disorders in patients with an underlying coeliac disease has been found. Anti-ganglioside antibodies may represent a new immunological marker to identify neurological impairment in patients with coeliac disease.     

Sorbitol H2-breath test versus anti-endomysium antibodies for the diagnosis of subclinical/silent coeliac disease.

BACKGROUND: Recent studies have shown that the prevalence of anti-endomysial antibodies (EMAs) in clinical practice is lower than expected; the aim of our study was therefore to compare the sorbitol H2-breath test (BT) with EMAs in the diagnosis of subclinical/silent coeliac disease and to compare with histologic lesions. METHODS: We studied 123 consecutive patients with subclinical (96) and silent (27) coeliac disease. Expiratory samples were collected before the patients drank the test solution (5 g of sorbitol in 150 ml of tap water) and every 30 min for 4 h. An increase in H2 concentration of at least 20 ppm over fasting baseline was considered positive for sorbitol malabsorption. EMAs were screened by the indirect immunofluorescence method. RESULTS: EMAs were positive in 77/96 (80.80%) and sorbitol H2-BT in 94/96 (97.91%) patients with subclinical coeliac disease, while EMAs were positive in 17/27 (62.96%) and sorbitol H2-BT in 26/27 (96.29%) patients with silent coeliac disease (P < 0.001 in both forms of coeliac disease). The best cut-off values in ppm and minutes are higher and shorter in the severe form than in the minor form of intestinal damage, respectively (P < 0.001 in both forms). CONCLUSIONS: This study indicates that almost all subclinical/silent coeliac patients show abnormal sorbitol H2-BT and that there is a strict correlation between cut-off value (in ppm and minutes) and histologic lesions. In particular, the maximal cut-off value (in ppm and in minutes) correlates statistically with the more severe the grade of intestinal damage. Finally, the prevalence of EMA in subclinical/silent disease is lower than expected.     

No harm from five year ingestion of oats in coeliac disease

BACKGROUND: Six to 12 months of ingestion of moderate amounts of oats does not have a harmful effect in adult patients with coeliac disease. As the safety of long term intake of oats in coeliac patients is not known, we continued our previous 6-12 month study for five years. AIM: To assess the safety of long term ingestion of oats in the diet of coeliac patients. PATIENTS: In our previous study, the effects of a gluten free diet and a gluten free diet including oats were compared in a randomised trial involving 92 adult patients with coeliac disease (45 in the oats group, 47 in the control group). After the initial phase of 6-12 months, patients in the oats group were allowed to eat oats freely in conjunction with an otherwise gluten free diet. After five years, 35 patients in the original oats group (23 still on an oats diet) and 28 in the control group on a conventional gluten free diet were examined. METHODS: Clinical and nutritional assessment, duodenal biopsies for conventional histopathology and histomorphometry, and measurement of antiendomysial, antireticulin, and antigliadin antibodies. RESULTS: There were no significant differences between controls and those patients consuming oats with respect to duodenal villous architecture, inflammatory cell infiltration of the duodenal mucosa, or antibody titres after five years of follow up. In both groups histological and histomorphometric indexes improved equally with time. CONCLUSIONS: This study provides the first evidence of the long term safety of oats as part of a coeliac diet in adult patients with coeliac disease. It also appears that the majority of coeliac patients prefer oats in their diet.     

Psychoneurotic symptoms and alexithymia in coeliac disease

Objective. Depression, psychological problems and the impairment of quality of life are reported to occur in untreated coeliac disease. Alexithymia (“no words for feelings”) is associated with various gastrointestinal disorders. The aim of this study was to evaluate whether patients with coeliac disease suffer from psychoneurotic symptoms or alexithymia, and whether a gluten-free diet has an impact on the symptoms. Material and methods. The Crown-Crisp Experiential Index (CCEI) and its six subscales were applied to measure neurotic psychopathology, and the 20-item version of the Toronto Alexithymia Scale (TAS-20) and its 3-factor scales to measure alexithymia. The testing was carried out in 20 consecutive adult patients with biopsy-proven coeliac disease before and after one year of treatment on a gluten-free diet. The data were compared with those obtained earlier in non-coeliac Finnish subjects. Results. Somatic anxiety was higher in coeliac disease patients before the introduction of the gluten-free diet than after adhering to the diet. Otherwise, the diet had no significant impact on the CCEI scores. The patients were not suffering from alexithymia, but the TAS-20 score improved significantly during the follow-up. The scores did not differ from those published in the Finnish population. Conclusions. Psychological problems were not common in adult coeliac disease patients. Gluten-free diet had only a minor influence on the symptoms. Common knowledge about coeliac disease and the readily available gluten-free products may have had an impact on these results.     

Should we screen reflux oesophagitis patients for coeliac disease?

OBJECTIVES: Oesophagitis and gastro-oesophageal reflux have been implicated recently in the manifestations of coeliac disease. The aim was to investigate this association in a primary-care setting. METHODS: First, the prevalence of coeliac disease was calculated in 1198 adults with oesophagitis, in 2541 adults with reflux symptoms and in 200 adults suffering from dysphagia; 5459 patients with a history consistent with dyspepsia and 709 patients with a suspicion of coeliac disease served as controls. Second, the prevalence of oesophagitis was estimated in 382 untreated and 232 treated coeliac patients; controls here comprised 5404 patients with dyspeptic symptoms and 2525 patients with reflux symptoms. Third, oesophagitis and oesophageal reflux symptoms were investigated before and after a gluten-free diet was followed in 67 adults with coeliac disease. The diagnosis of coeliac disease was based on small-bowel histology; histological exclusion of the disease was unambiguous in all controls. Oesophagitis was identified by endoscopic inspection. RESULTS: Altogether, 0.9% of patients with oesophagitis and 0.6% of those with oesophageal reflux symptoms had coeliac disease. The corresponding percentages were 1.0% in patients with dyspepsia and 12% with suspicion of coeliac disease. The prevalence of oesophagitis was 5.2% in untreated coeliac disease, 5.6% in treated coeliac disease, 7.0% in patients with dyspepsia, and 27% in symptomatic reflux disease. In coeliac patients, the reflux symptoms were mild but nevertheless were alleviated on a gluten-free diet. CONCLUSIONS: This study does not support the conception that patients with reflux oesophagitis should be screened vigorously for coeliac disease. The association between these two conditions is, at most, weak, but a gluten-free diet may still bring symptomatic relief for reflux symptoms in coeliac disease.     

Extreme thrombocytosis as a sign of coeliac disease in the elderly: case report

Increase in the number of blood platelets to over 1,000,000/mm3 in elderly patients is generally considered secondary to a myeloproliferative or neoplastic disease. To report the case of an elderly woman hospitalized for extreme thrombocytosis associated with severe anaemia, who was found to be suffering from coeliac disease. The patient, aged 83 years, was hospitalized presenting with fatigue. Laboratory tests showed microcytic hypochromic anaemia (haemoglobin 4 g/dl) and extreme thrombocytosis (platelet count 1,400,000/mm3). Physical examination was normal, with the exception of marked thinness. There was no evidence of macroscopic bleeding from the gastrointestinal or genitourinary tracts. She had never suffered from gastrointestinal problems and had no family history of gastroenterological diseases. Oesophagogastroduodenoscopy and histology of the gastric and duodenal mucosa evidenced atrophic gastritis and an adenomatous polyp. The duodenal mucosa showed total villous atrophy, suggesting the diagnosis of coeliac disease. Antiendomysial IgA and anti-transglutaminase IgA antibodies were also positive. Colonoscopy was negative. An ultrasound examination of the abdomen was normal, and the spleen was within the normal range. A peripheral blood smear showed no alterations in erythrocyte morphology typical of hyposplenism due to coeliac disease. The platelet count decreased rapidly after blood transfusions, when both serum iron and ferritin levels were still below normal limits. Furthermore, we observed a significant inverse correlation between the platelet count and haemoglobin concentration (r = -0.94, P < 0.003). Platelet count and red blood cell count normalized after 2 months of a gluten-free diet; the haemoglobin concentration was also normal at this time. After 1 year of following a gluten-free diet, the patient remained well and had no complaints. There were no gastrointestinal disturbances. All haematological parameters were within normal limits. Intestinal biopsies showed normal villi and crypts without inflammatory infiltration of the lamina propria. This case shows that the association of haematological signs--extreme thrombocytosis and severe anaemia--considered in an elderly patient to be typical of myeloproliferative disorders or neoplastic conditions can be due to coeliac disease; thus, coeliac disease must also be considered among the possible diagnoses.     

IgA antigliadin antibodies and persistence of jejunal lesions in adult coeliac disease

In 46 adult patients with coeliac disease, 41 (89%) of whom were positive for IgA and/or IgG antigliadin antibodies (AGA) when untreated, we investigated after a gluten-free diet the relationship between the persistence of AGA, the persistence of jejunal lesions, and the duration and compliance with the diet. IgG AGA were positive in 21 coeliac patients (46%) after variable periods of gluten-free diet and were associated with IgA positivity only in 4 cases (9%). Both IgA and IgG AGA positivity appeared to be more related to the lack of improvement of the jejunal lesions than to the strictness and duration of gluten withdrawal. Nine coeliacs showed no improvement of jejunal lesions after the gluten-free diet. Of these 9, 4 showed persistent IgA AGA, while the remaining 5 resulted IgAAGA-negative as before when untreated. Though intestinal biopsy remains the best means of determining the positive effect of gluten withdrawal, the persistence of IgA AGA in treated coeliacs is always predictive of the persistence of severe jejunal lesions. The persistence of IgG AGA, on the contrary, should be regarded as an immunological memory.