Wednesday, February 15, 2012

Early Diagnosis of Gluten Sensitivity: Before the Villi are Gone by By Kenneth Fine, M.D.

I find the Journal of Gluten Sensitivity most helpful. It's a by subscription only journal and is mailed to you. Dr. Fine, a pre-eminent gastroenterologist, has lots of wise advice when it comes to celiac or gluten sensitivity. He believes in early diagnosis as I do.

This article originally appeared in the Winter 2004 edition of Celiac.com's Scott-Free Newsletter. Transcript of a talk given by Kenneth Fine, M.D. to the Greater Louisville Celiac Sprue Support Group––transcribed by Marge Johannemann; Edited by Kelly Vogt.
Celiac.com 03/04/2004 - Gluten sensitivity is the process by which the immune system reacts to gluten contained in wheat, barley, rye, and oats. The reaction begins in the intestine because that is where the inciting antigen, gluten, is present (from food). When this immunologic reaction damages the finger-like surface projections, the villi, in the small intestine (a process called villous atrophy), it is called celiac disease (or sometimes celiac sprue or gluten-sensitive enteropathy). The clinical focus of gluten-induced disease has always been on the intestine because that is the only way the syndrome was recognized before screening tests were developed. The intestinal syndrome consists mainly of diarrhea, gas, bloating, nausea, vomiting, fat in the stool, nutrient malabsorption, and even constipation. Although the small intestine is always the portal of the immune response to dietary gluten, it is not always affected in a way that results in villous atrophy. Even though recent research has shown that celiac disease is much more common than previously suspected, affecting 1 in 100-200 Americans and Europeans, past and emerging evidence indicates that it accounts for only a small portion of the broader gluten sensitive clinical spectrum (often referred to as the “Tip of the Gluten Sensitive Iceberg”). With better understanding of how gluten triggers immune and autoimmune reactions in the body under the control of various genes, and advancing techniques of detecting these reactions, it is becoming apparent that the majority of the gluten sensitive population (the submerged “mass of the iceberg”) do not manifest villous atrophy in its classic, complete form and therefore do not have celiac disease. In these non-celiac, gluten sensitive individuals, the brunt of the immune reaction either affects the function of the intestine, causing symptoms without structural damage, affects other tissues of the body (and virtually all tissues have been affected in different individuals), or both. This is important because the commonly used diagnostic tests of clinically important gluten sensitivity (blood tests for certain antibodies and intestinal biopsies) are only positive when villous atrophy of the small intestine is present. But if only a small minority of gluten sensitive individuals actually develop celiac disease, the majority, who have not yet or may never develop villous atrophy, with or without symptoms, can remain undiagnosed and untreated for years. This can result in significant immune and nutritional consequences, many of which are irreversible even after treatment with a gluten-free diet. Some of these disorders include loss of hormone secretion by glands (hypothyroidism, diabetes, pancreatic insufficiency, etc), osteoporosis, short stature, cognitive impairment, and other inflammatory bowel, liver, and skin diseases, and cancer among others. Only with early diagnosis, can these problems be prevented or reversed.
I am here to report on a scientific paradigm shift regarding early diagnosis of gluten sensitivity based on about 30 years of medical research by myself and others. My message is that earlier and more inclusive diagnosis of gluten sensitivity than has been allowed by blood tests and intestinal biopsies must be developed to prevent the nutritional and immune consequences of long-standing gluten sensitivity. Imagine going to a cardiologist because your blood pressure is high or you’re having chest pain, and the doctor says he is going to do a biopsy of your heart to see what is wrong. If it ‘looks’ O.K., you are told you have no problem and no treatment is prescribed because you have not yet had a heart attack showing on the biopsy. You would not think very highly of the doctor utilizing this approach because, after all, isn’t it damage to the heart that you would want to prevent? But for the intestine and gluten sensitivity, current practice embraces this fallacious idea that until an intestinal biopsy shows structural damage, no diagnosis or therapeutic intervention is offered. 

You can find out more about Dr. Fine and his lab tests at www.enterolab.com and read his full article about early diagnosis at  www.enterolab.com. 

Hepatitis vaccination failure high in a person with celiac disease

The HBV vaccine is usually effective against common hepatitis B virus (HBV) infection, with just 4-10% of vaccine recipients failing to respond to standard immunization. Some studies suggest that people with celiac disease may have high levels of failure to develop antibodies to HBV after immunization with the HBV vaccine, compared to the general population. The vaccine fails to take. 

The ability to respond to recombinant HBV vaccine is associated with certain gene sites. At those sites, certain HLA Haplotypes, such as B8, DR3, and DQ2 are common genetic markers among non-responders98% of people with celiac disease have the HLA Haplotype DQ2.

Hoping to understand this phenomenon better, a group of doctors from the Research Center for Gastroenterology  and Liver Disease at Shahid Beheshti University of Medical Sciences in Tehran, Iran, and with Acute Medicine at Dudley Group of Hospital in Dudley, UK  reviewed data from previous studies.

They conclude... (My bolds)…....Longer intervals between vaccination and antibody testing might be one of the reasons for significantly low protective post-vaccination HBV antibody titers even in CD patients who comply with dietary guidelines [8][14]. Therefore, revaccination is recommended when the patients are following a controlled gluten-free diet.
This study was not designed to determine the presence of HLA-DQ2 and HLA-DQ8 in both the groups. Therefore, future studies evaluating the HLA haplotypes in CD and control groups should aim to characterize the role of HLA typing in the response to HBV vaccination.
As in the case of other conditions and as indicated by the strong evidence for the protective role of GFD, early diagnosis of CD may obviously increase the percentage of patients responding to the HBV vaccine. Moreover, beginning with a short duration, strict, gluten-free diet seems to play a positive role in the development of antibody memory. Given the high prevalence of CD in the general population and a lack of response to HBV vaccine in untreated patients, we think that non-responsiveness to HBV vaccine necessitates routine assessment in patients with CD. Non-responsiveness to HBV vaccine may be a possible sign of undiagnosed CD or may suggest noncompliance with gluten-free diet.
                                                                                                                                                

The evidence indicates that early diagnosis of celiac disease, and strong recommendation and treatment with a gluten-free diet may increase the overall percentage of patients responding favorably to the HBV vaccine. 

The review team points out that the high prevalence of celiac disease in the general population and a lack of response to HBV vaccine in untreated patients, invites routine assessment in patients with celiac disease receiving the HBV vaccine, to include whether or not they are on a strict gluten free diet. Vaccinate only after a few months on GF diet.

Lastly, the review team notes that non-responsiveness to HBV vaccine should trigger some suspicion that the person may have undiagnosed celiac disease or noncompliance with gluten-free diet if the person already knows they are celiac.

And that is how we are going to get more people properly diagnosed so that they get on a strict gluten free diet and will have 10-20 more healthy years added to their lives.









Hepatitis vaccination failure high in a person with celiac disease


The HBV vaccine is usually effective against common hepatitis B virus (HBV) infection, with just 4-10% of vaccine recipients failing to respond to standard immunization. Some studies suggest that people with celiac disease may have high levels of failure to develop antibodies to HBV after immunization with the HBV vaccine, compared to the general population. The vaccine fails to take. 


The ability to respond to recombinant HBV vaccine is associated with certain gene sites. At those sites, certain HLA Haplotypes, such as B8, DR3, and DQ2 are common genetic markers among non-responders. 98% of people with celiac disease have the HLA Haplotype DQ2.


Hoping to understand this phenomenon better, a group of doctors from the Research Center for Gastroenterology  and Liver Disease at Shahid Beheshti University of Medical Sciences in Tehran, Iran, and with Acute Medicine at Dudley Group of Hospital in Dudley, UK  reviewed data from previous studies.


They conclude... (My bolds)…....Longer intervals between vaccination and antibody testing might be one of the reasons for significantly low protective post-vaccination HBV antibody titers even in CD patients who comply with dietary guidelines [8][14]. Therefore, revaccination is recommended when the patients are following a controlled gluten-free diet.
This study was not designed to determine the presence of HLA-DQ2 and HLA-DQ8 in both the groups. Therefore, future studies evaluating the HLA haplotypes in CD and control groups should aim to characterize the role of HLA typing in the response to HBV vaccination.
As in the case of other conditions and as indicated by the strong evidence for the protective role of GFD, early diagnosis of CD may obviously increase the percentage of patients responding to the HBV vaccine. Moreover, beginning with a short duration, strict, gluten-free diet seems to play a positive role in the development of antibody memory. Given the high prevalence of CD in the general population and a lack of response to HBV vaccine in untreated patients, we think that non-responsiveness to HBV vaccine necessitates routine assessment in patients with CD. Non-responsiveness to HBV vaccine may be a possible sign of undiagnosed CD or may suggest noncompliance with gluten-free diet.
                                                                                                                                                


The evidence indicates that early diagnosis of celiac disease, and strong recommendation and treatment with a gluten-free diet may increase the overall percentage of patients responding favorably to the HBV vaccine. 


The review team points out that the high prevalence of celiac disease in the general population and a lack of response to HBV vaccine in untreated patients, invites routine assessment in patients with celiac disease receiving the HBV vaccine, to include whether or not they are on a strict gluten free diet. Vaccinate only after a few months on GF diet.


Lastly, the review team notes that non-responsiveness to HBV vaccine should trigger some suspicion that the person may have undiagnosed celiac disease or noncompliance with gluten-free diet if the person already knows they are celiac.


And that is how we are going to get more people properly diagnosed so that they get on a strict gluten free diet and will have 10-20 more healthy years added to their lives.