69 Case Finding of Clinically Silent Celiac Disease by Rapid Fingertip Point of Care Test
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AGA Abstracts or D) PR61α doxycycline-inducible Lim2405 cells were incubated with doxycycline or without doxycycline. WST1 values were measured daily. 50 SOX9 Regulates Cell Proliferation Through Activation of Igfbp-4 in Apcmin/+ Adenomas and Colorectal Cancer Cells Zhongcheng Shi, Chi-I Chiang, Yuko Mori-Akiyama BACKGROUND & AIMS: In the normal intestinal epithelium, SOX9 expression is localized in the crypt cells. SOX9 is also expressed in diverse cancers, including colorectal cancer (CRC). Our previous loss-of-function study showed increased proliferation in Sox9-deficient crypts, indicating SOX9 suppresses cellular proliferation. We examined role of SOX9 in proliferation of normal intestinal epithelium, Apcmin/+ mouse adenomas, and CRC cells. METHODS: Sox9 deficient Apcmin/+mice were generated to investigate role of SOX9 in tumorigenesis. Crypt epithelial cells isolated from Sox9-deficient mice were also used to identify the potential target genes of SOX9. RESULTS: Sox9 deficiency in Apcmin/+ mice resulted in increased tumor burden relative to Apcmin/+ control mice. Insulin-like growth factor-binding protein 4 (IGFBP-4), a well documented inhibitor of the IGF/IGFR axis, was significantly downregulated in Sox9-deficient intestinal epithelial cells as well as in adenoma cells of Sox9-deficient Apcmin/+ mice. Co-staining experiments revealed colocalization of IGFBP-4 and SOX9 in mouse and human intestinal epithelial cells as well as primary CRC specimens. Reporter assays and chromatin immunoprecipitation (ChIP) demonstrated direct binding of SOX9 to IGFBP-4 promoter. Overexpression of SOX9 attenuated cellular prolifera- tion, which was restored following treatment with a neutralizing antibody against IGFBP- 4, suggesting that SOX9 requires IGFBP-4 to suppress cellular proliferation. CONCLUSION: SOX9 suppresses cellular proliferation in intestinal epithelium, adenoma cells of Apcmin/+ mice, and CRC cells through activation of IGFBP-4. 67 How Do the 2012 Espghan Coeliac Disease Guidelines Perform in a GI Clinic Dominica Gidrewicz, Martha E. Lyon, Cynthia Trevenen, J. Decker Butzner Background and Aims: We retrospectively evaluated the 2012 ESPGHAN Coeliac Guideline recommendation for the elimination of an intestinal biopsy in selected children with suspected celiac disease (CD). Criteria for a diagnosis without biopsy include: symptoms or signs of CD, an IgA-tTG .10 x ULN, a positive anti-endomysial antibody (EMA) and positive HLA DQ2/8 testing. Methods: We utilized the Calgary Laboratory Services (CLS) database of 18 243 consecutive IgA-tTG results (Euroimmune) collected in 16 402 children under age 18 years (10 mo-17.9 yr) between July 2008 and December 2011. We used the CLS pathology database to obtain all results with the diagnosis of CD, partial or total villus atrophy. A pathologist reviewed appropriate biopsies and assigned a Marsh score. Results: In this cohort, 829 patients (5.0%; 95%CI, 4.7-5.4%) had a positive tTG ( .20 kU/L) of which 352 (42.4%; 39-46%) had a tTG .10 x ULN ( .200 kU/L). Of the 352, 342 (97.2%; 94.7- 98.5%) had positive EMA serology (IMMCO Diagnostics) and 277 (81%; 76.3-84.9%) had an intestinal biopsy (221 symptomatic, 56 asymptomatic with a CD associated condition). Of the 221 symptomatic children with a tTG .200 kU/L and positive EMA, 217 (98.2%; 95.1-99.4%) were diagnosed with CD based on Marsh 2/3 histologic criteria (209 Marsh 3, 8 Marsh 2). Four children with symptoms (1.8%; 0.6- 5.0%) who met the "non-biopsy" criteria had biopsies that were not diagnostic of CD (Table). Of these four children with false positive serology, three had abnormal intestinal biopsies with normal intraepithelial lymphocyte counts, and all were DQ2/8 positive. Ten children with a tTG .10 x ULN had a negative EMA and the following characteristics: biopsies not diagnostic of CD (5), biopsy proven CD (4) and not referred (1). Of the 54 asymptomatic patients, 50 (92.5%; 81.2- 97.6%) were diagnosed with CD. The 65 patients with a tTG .200 kU/L and positive EMA did not undergo biopsy for the following reasons: follow-up of known CD (8), not referred (32), or family refused endoscopy (25). We can achieve a positive predictive value (PPV) of 100% by applying the guidelines to symptomatic patients, with tTG .200 kU/L and EMA .1:80, a relatively high EMA titre. This would reduce the number of endoscopies by 130 over the study period. Conclusions: Application of the new ESPGHAN "non-biopsy" algorithm to our cohort resulted in a PPV of 98%. However 2% of children, who met the ESPGHAN "non-biopsy" criteria, would have been incorrectly diagnosed with CD. DQ2/ DQ8 testing was not helpful in these patients. The algorithm PPV is further reduced if no EMA verification is performed or if it is applied to asymptomatic children with CD associated conditions. Adoption of the ESPGHAN criteria for the "non-biopsy" diagnosis of CD will relieve the stress of an invasive procedure in children and families as well as reduce costs. Table 1 - Patients with positive celiac serology but negative biopsy results Sx, symptoms; ND, nondiagnostic; IEL, intraepithelial lymphocytes; VB, villous blunting; LP, lamina propria; DD, descending duodenum S-14 AGA Abstracts 68 A Multicenter Review of the New Espghan Guidelines for Celiac Disease: How Many Biopsies Can We Really Skip? Catherine D. Newland, Julia M. Bracken, Kiranmai Gorla, NurAlima Grandison, Stefano Guandalini Background: The diagnostic criteria for celiac disease (CD) were recently reviewed and a new set of guidelines published by the European Society of Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) in January of 2012. The aims of this study were: 1) to retrospectively determine how many patients would avoid the biopsy; and 2) to verify potential drawbacks in eliminating endoscopy. Methods: A retrospective chart review was performed on pediatric patients diagnosed with celiac disease at three institutions: the University of Chicago Celiac Center from August 2008 to May 2012, Children's Mercy Hospitals and Clinics, Kansas City from January 2009 to September 2012 and the Center for Children's Digestive Health, Chicago from January 2010 to November 2012. Information was collected on patients with a diagnosis of CD including: gender, date of birth, date of diagnosis, symptoms, endoscopic pathology findings, and celiac serologies. Results: A total of 482 records of pediatric CD patients were reviewed. Among them, 203 patients (135 females) had data available for both tissue transglutaminase IgA (tTG IgA) and endomysial antibodies (EMA) at presentation. Average age at diagnosis was 8.8 years. Ninety-four patients (46%) had tTG greater than 10 times the upper limit of normal and a positive EMA. Of these 94 patients, 83 (88%) underwent endoscopy with biopsies with the distribution of Marsh scores as follows: Marsh 0 - 2 (2.4%), Marsh 1 - 5 (6 %), Marsh 2 - 21 (25.3%), Marsh 3 - 55 (66.3%). Of interest, 20 (24.1%) of the biopsied patients had additional, unexpected diagnoses found on pathology including, chronic gastritis (12), reflux esophagitis (5), esophagitis (2), eosinophilic esophagitis (1), and H. pylori (1). Conclusion: Almost half of the pediatric patients diagnosed with celiac disease in this multi-center series would have met the new ESPGHAN criteria allowing to forgo duodenal biopsy. Avoiding the procedure would eliminate risk to the patient and drastically reduce healthcare costs as much as $10,000 per patient. However, by avoiding the diagnostic procedure, additional, unexpected diagnoses would have been missed in as many as a quarter of such patients. 69 Case Finding of Clinically Silent Celiac Disease by Rapid Fingertip Point of Care Test Mariana Jinga, Alina Popp, Ciprian Jurcut, Daniel Vasile Balaban, Catalina I. Bardas, Kaija Laurila, Florina Vasilescu, Adina Ene, Alina I. Anca, Markku Mäki Background: Serum autoantibodies measured from fingertip whole blood by a rapid point of care test (POCT) and used in primary health care outpatient setting might be a powerful tool for case finding of celiac disease (CD). In the present study we evaluated the use of POCT in detecting CD among first degree relatives of CD patients. Methods: All 170 first degree relatives of 70 Romanian index cases with biopsy-proven CD (Marsh 3 small-bowel mucosal lesion) were invited to be evaluated for the presence of CD autoantibodies. Altogether 148 subjects agreed (median age 36 years, range 1.2-77 years) and 22 could not been reached or refused the screening. The on site evaluation was performed using fingertip Biocard Celiac Test, Anibiotech, Vantaa, Finland. Sera were also drawn of for IgA-class endomysial antibodies (EMA, Nova Lite, Inova Diagnostics). Positivity in the EMA test was checked further for IgA class tissue transglutaminase 2 antibodies (TG2-IgA) (Celikey, Phadia, Germany). All serologic determinations were done in a blinded fashion in the centralized laboratory without knowledge of the on site POCT result. Upper gastrointestinal endoscopy with small bowel mucosal biopsies was recommended to POCT and EMA positive subjects. The study was ethically approved. Results: In on site testing the POCT was positive in 12/ 148 first degree relatives (8.1%). All 12 POCT positive subjects were also EMA positive and only one more positive subject was found. Four subjects positive for both POCT and EMA were negative for TG2-IgA when the cut-off for positivity was set at 5 U/ml. When setting the cut-off at 3U/ml then EMA positive subjects were TG2-IgA positive too. Ten out of thirteen of the antibody positive subjects agreed to undergo endoscopy. POCT was found to be positive in 8/9 first-degree relatives having celiac-type mucosal lesions of grade Marsh 2 (n=2) or Marsh 3 (n=6). The three POCT positive subjects not agreeing to undergo endoscopy were also both EMA and TG2-IgA positive. Conclusion: The fingertip whole blood rapid POCT might fulfill the unmet need for a simple and cheap case finding biomarker for undiagnosed CD to be used on site in the outpatient clinic in the primary care. 70 Serum I-Fabp Is a Useful Tool for Evaluation of Gluten Challenge in Adults With Celiac Disease Marlou Adriaanse, Daniel A. Leffler, Ciaran P. Kelly, Detlef Schuppan, Wim A. Buurman, Anita Vreugdenhil Introduction: Response to gluten challenge is a key outcome in diagnostic algorithms and trials of novel therapies in celiac disease (CD). Long-time gluten challenge (GC) often leads to severe symptoms and for this reason, there is resistance from patients to this approach. As the antibody response in CD is delayed in comparison with histological changes, a responsive and reliable non-invasive marker for evaluation of mucosal damage after GC would be useful in research and clinical practice. Intestinal fatty acid binding protein (I- FABP), a marker for intestinal epithelial damage, has been hypothesized as a novel marker of mucosal injury in CD. This study investigated the accuracy of serum I-FABP for the evaluation of intestinal damage in patients with CD during GC. Methods: Twenty adult CD patients in clinical remission (tTG ,10 U/ml, .12 months on a strict GFD with a celiac dietary adherence score ,18 and absence of symptoms) underwent a GC with 3 or 7.5 grams of gluten per day. Study visits occurred at -14, 0, 3, 7, 14 and 28 days after starting GC. Serum I-FABP, IgA-tTG, IgA-DGP and symptoms were assessed at each visit. Duodenal biopsy was performed at day -14, 3 and 14 of GC and scored for villous height:crypt dept- ratio (Vh:Cd) and intraepithelial lymphocyte (IEL) count. Results: Serum I-FABP levels increased significantly from baseline to day 14 of GC and decreased after withdrawal of
Transcript of 69 Case Finding of Clinically Silent Celiac Disease by Rapid Fingertip Point of Care Test
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sor D) PR61α doxycycline-inducible Lim2405 cells were incubated with doxycycline orwithout doxycycline. WST1 values were measured daily.
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SOX9 Regulates Cell Proliferation Through Activation of Igfbp-4 in Apcmin/+Adenomas and Colorectal Cancer CellsZhongcheng Shi, Chi-I Chiang, Yuko Mori-Akiyama
BACKGROUND & AIMS: In the normal intestinal epithelium, SOX9 expression is localizedin the crypt cells. SOX9 is also expressed in diverse cancers, including colorectal cancer(CRC). Our previous loss-of-function study showed increased proliferation in Sox9-deficientcrypts, indicating SOX9 suppresses cellular proliferation. We examined role of SOX9 inproliferation of normal intestinal epithelium, Apcmin/+ mouse adenomas, and CRC cells.METHODS: Sox9 deficient Apcmin/+mice were generated to investigate role of SOX9 intumorigenesis. Crypt epithelial cells isolated from Sox9-deficient mice were also used toidentify the potential target genes of SOX9. RESULTS: Sox9 deficiency in Apcmin/+ miceresulted in increased tumor burden relative to Apcmin/+ control mice. Insulin-like growthfactor-binding protein 4 (IGFBP-4), a well documented inhibitor of the IGF/IGFR axis, wassignificantly downregulated in Sox9-deficient intestinal epithelial cells as well as in adenomacells of Sox9-deficient Apcmin/+ mice. Co-staining experiments revealed colocalization ofIGFBP-4 and SOX9 in mouse and human intestinal epithelial cells as well as primary CRCspecimens. Reporter assays and chromatin immunoprecipitation (ChIP) demonstrated directbinding of SOX9 to IGFBP-4 promoter. Overexpression of SOX9 attenuated cellular prolifera-tion, which was restored following treatment with a neutralizing antibody against IGFBP-4, suggesting that SOX9 requires IGFBP-4 to suppress cellular proliferation. CONCLUSION:SOX9 suppresses cellular proliferation in intestinal epithelium, adenoma cells of Apcmin/+mice, and CRC cells through activation of IGFBP-4.
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How Do the 2012 Espghan Coeliac Disease Guidelines Perform in a GI ClinicDominica Gidrewicz, Martha E. Lyon, Cynthia Trevenen, J. Decker Butzner
Background and Aims: We retrospectively evaluated the 2012 ESPGHAN Coeliac Guidelinerecommendation for the elimination of an intestinal biopsy in selected childrenwith suspectedceliac disease (CD). Criteria for a diagnosis without biopsy include: symptoms or signs ofCD, an IgA-tTG .10 x ULN, a positive anti-endomysial antibody (EMA) and positive HLADQ2/8 testing. Methods: We utilized the Calgary Laboratory Services (CLS) database of 18243 consecutive IgA-tTG results (Euroimmune) collected in 16 402 children under age 18years (10 mo-17.9 yr) between July 2008 and December 2011. We used the CLS pathologydatabase to obtain all results with the diagnosis of CD, partial or total villus atrophy. Apathologist reviewed appropriate biopsies and assigned a Marsh score. Results: In thiscohort, 829 patients (5.0%; 95%CI, 4.7-5.4%) had a positive tTG ( .20 kU/L) of which352 (42.4%; 39-46%) had a tTG .10 x ULN (.200 kU/L). Of the 352, 342 (97.2%; 94.7-98.5%) had positive EMA serology (IMMCO Diagnostics) and 277 (81%; 76.3-84.9%) hadan intestinal biopsy (221 symptomatic, 56 asymptomatic with a CD associated condition).Of the 221 symptomatic children with a tTG .200 kU/L and positive EMA, 217 (98.2%;95.1-99.4%) were diagnosed with CD based on Marsh 2/3 histologic criteria (209 Marsh3, 8 Marsh 2). Four children with symptoms (1.8%; 0.6- 5.0%) who met the "non-biopsy"criteria had biopsies that were not diagnostic of CD (Table). Of these four children withfalse positive serology, three had abnormal intestinal biopsies with normal intraepitheliallymphocyte counts, and all were DQ2/8 positive. Ten children with a tTG .10 x ULN hada negative EMA and the following characteristics: biopsies not diagnostic of CD (5), biopsyproven CD (4) and not referred (1). Of the 54 asymptomatic patients, 50 (92.5%; 81.2-97.6%) were diagnosed with CD. The 65 patients with a tTG .200 kU/L and positive EMAdid not undergo biopsy for the following reasons: follow-up of known CD (8), not referred(32), or family refused endoscopy (25). We can achieve a positive predictive value (PPV)of 100% by applying the guidelines to symptomatic patients, with tTG .200 kU/L andEMA .1:80, a relatively high EMA titre. This would reduce the number of endoscopies by130 over the study period. Conclusions: Application of the new ESPGHAN "non-biopsy"algorithm to our cohort resulted in a PPV of 98%. However 2% of children, who met theESPGHAN "non-biopsy" criteria, would have been incorrectly diagnosed with CD. DQ2/DQ8 testing was not helpful in these patients. The algorithm PPV is further reduced if noEMA verification is performed or if it is applied to asymptomatic children with CD associatedconditions. Adoption of the ESPGHAN criteria for the "non-biopsy" diagnosis of CD willrelieve the stress of an invasive procedure in children and families as well as reduce costs.Table 1 - Patients with positive celiac serology but negative biopsy results
Sx, symptoms; ND, nondiagnostic; IEL, intraepithelial lymphocytes; VB, villous blunting;LP, lamina propria; DD, descending duodenum
S-14AGA Abstracts
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A Multicenter Review of the New Espghan Guidelines for Celiac Disease: HowMany Biopsies Can We Really Skip?Catherine D. Newland, Julia M. Bracken, Kiranmai Gorla, NurAlima Grandison, StefanoGuandalini
Background: The diagnostic criteria for celiac disease (CD) were recently reviewed and anew set of guidelines published by the European Society of Pediatric GastroenterologyHepatology and Nutrition (ESPGHAN) in January of 2012. The aims of this study were: 1)to retrospectively determine how many patients would avoid the biopsy; and 2) to verifypotential drawbacks in eliminating endoscopy. Methods: A retrospective chart review wasperformed on pediatric patients diagnosed with celiac disease at three institutions: theUniversity of Chicago Celiac Center from August 2008 to May 2012, Children's MercyHospitals and Clinics, Kansas City from January 2009 to September 2012 and the Centerfor Children's Digestive Health, Chicago from January 2010 to November 2012. Informationwas collected on patients with a diagnosis of CD including: gender, date of birth, date ofdiagnosis, symptoms, endoscopic pathology findings, and celiac serologies. Results: A totalof 482 records of pediatric CD patients were reviewed. Among them, 203 patients (135females) had data available for both tissue transglutaminase IgA (tTG IgA) and endomysialantibodies (EMA) at presentation. Average age at diagnosis was 8.8 years. Ninety-four patients(46%) had tTG greater than 10 times the upper limit of normal and a positive EMA. Ofthese 94 patients, 83 (88%) underwent endoscopy with biopsies with the distribution ofMarsh scores as follows: Marsh 0 - 2 (2.4%), Marsh 1 - 5 (6 %), Marsh 2 - 21 (25.3%),Marsh 3 - 55 (66.3%). Of interest, 20 (24.1%) of the biopsied patients had additional,unexpected diagnoses found on pathology including, chronic gastritis (12), reflux esophagitis(5), esophagitis (2), eosinophilic esophagitis (1), and H. pylori (1). Conclusion: Almost halfof the pediatric patients diagnosed with celiac disease in this multi-center series would havemet the new ESPGHAN criteria allowing to forgo duodenal biopsy. Avoiding the procedurewould eliminate risk to the patient and drastically reduce healthcare costs as much as$10,000 per patient. However, by avoiding the diagnostic procedure, additional, unexpecteddiagnoses would have been missed in as many as a quarter of such patients.
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Case Finding of Clinically Silent Celiac Disease by Rapid Fingertip Point ofCare TestMariana Jinga, Alina Popp, Ciprian Jurcut, Daniel Vasile Balaban, Catalina I. Bardas, KaijaLaurila, Florina Vasilescu, Adina Ene, Alina I. Anca, Markku Mäki
Background: Serum autoantibodies measured from fingertip whole blood by a rapid pointof care test (POCT) and used in primary health care outpatient setting might be a powerfultool for case finding of celiac disease (CD). In the present study we evaluated the use ofPOCT in detecting CD among first degree relatives of CD patients. Methods: All 170 firstdegree relatives of 70 Romanian index cases with biopsy-proven CD (Marsh 3 small-bowelmucosal lesion) were invited to be evaluated for the presence of CD autoantibodies. Altogether148 subjects agreed (median age 36 years, range 1.2-77 years) and 22 could not beenreached or refused the screening. The on site evaluation was performed using fingertipBiocard Celiac Test, Anibiotech, Vantaa, Finland. Sera were also drawn of for IgA-classendomysial antibodies (EMA, Nova Lite, Inova Diagnostics). Positivity in the EMA test waschecked further for IgA class tissue transglutaminase 2 antibodies (TG2-IgA) (Celikey, Phadia,Germany). All serologic determinations were done in a blinded fashion in the centralizedlaboratory without knowledge of the on site POCT result. Upper gastrointestinal endoscopywith small bowel mucosal biopsies was recommended to POCT and EMA positive subjects.The study was ethically approved. Results: In on site testing the POCT was positive in 12/148 first degree relatives (8.1%). All 12 POCT positive subjects were also EMA positive andonly one more positive subject was found. Four subjects positive for both POCT and EMAwere negative for TG2-IgA when the cut-off for positivity was set at 5 U/ml. When settingthe cut-off at 3U/ml then EMA positive subjects were TG2-IgA positive too. Ten out ofthirteen of the antibody positive subjects agreed to undergo endoscopy. POCT was foundto be positive in 8/9 first-degree relatives having celiac-type mucosal lesions of grade Marsh2 (n=2) or Marsh 3 (n=6). The three POCT positive subjects not agreeing to undergoendoscopy were also both EMA and TG2-IgA positive. Conclusion: The fingertip wholeblood rapid POCT might fulfill the unmet need for a simple and cheap case finding biomarkerfor undiagnosed CD to be used on site in the outpatient clinic in the primary care.
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Serum I-Fabp Is a Useful Tool for Evaluation of Gluten Challenge in AdultsWith Celiac DiseaseMarlou Adriaanse, Daniel A. Leffler, Ciaran P. Kelly, Detlef Schuppan, Wim A. Buurman,Anita Vreugdenhil
Introduction: Response to gluten challenge is a key outcome in diagnostic algorithms andtrials of novel therapies in celiac disease (CD). Long-time gluten challenge (GC) often leadsto severe symptoms and for this reason, there is resistance from patients to this approach.As the antibody response in CD is delayed in comparison with histological changes, aresponsive and reliable non-invasive marker for evaluation of mucosal damage after GCwould be useful in research and clinical practice. Intestinal fatty acid binding protein (I-FABP), a marker for intestinal epithelial damage, has been hypothesized as a novel markerof mucosal injury in CD. This study investigated the accuracy of serum I-FABP for theevaluation of intestinal damage in patients with CD during GC. Methods: Twenty adult CDpatients in clinical remission (tTG,10 U/ml, .12 months on a strict GFD with a celiacdietary adherence score ,18 and absence of symptoms) underwent a GC with 3 or 7.5grams of gluten per day. Study visits occurred at -14, 0, 3, 7, 14 and 28 days after startingGC. Serum I-FABP, IgA-tTG, IgA-DGP and symptoms were assessed at each visit. Duodenalbiopsy was performed at day -14, 3 and 14 of GC and scored for villous height:crypt dept-ratio (Vh:Cd) and intraepithelial lymphocyte (IEL) count. Results: Serum I-FABP levelsincreased significantly from baseline to day 14 of GC and decreased after withdrawal of
