Celiac Disease: Genetics, Triggers, and Gallbladder Function

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Questions and Answers

What is the primary trigger for celiac disease (CD) in genetically predisposed individuals?

  • Inflammation of the gallbladder
  • Autoimmune response to gut bacteria
  • Viral infections affecting the small intestine
  • Intake of gluten (correct)

Which genetic factors are most relevant in predisposing individuals to celiac disease?

  • Mutations affecting intestinal permeability
  • Polymorphisms in genes regulating bile acid synthesis
  • Variations in the MHC-DR4 heterodimers
  • Allelic variants related to MHC-DQ2 and/or MHC-DQ8 heterodimers (correct)

Which of the following HLA-DQB1 alleles is most strongly associated with celiac disease predisposition?

  • HLA-DQB1*0301
  • HLA-DQB1*0101
  • HLA-DQB1*0402
  • HLA-DQB1*02 (correct)

What is the typical outcome of gallbladder impairment in CD patients who adhere to a gluten-free diet?

<p>The impairment is often reversible (B)</p> Signup and view all the answers

Why might the correlation between celiac disease and gallbladder complications be underestimated in current clinical understanding?

<p>Recent improvements in CD diagnosis have reduced diagnostic delay and subsequent complications (B)</p> Signup and view all the answers

What type of study is needed to better understand the clinical implications of gallbladder alterations in CD patients?

<p>Specific clinical investigations focused on gallbladder alterations in CD patients (B)</p> Signup and view all the answers

What does the statement 'this genetic background is necessary, but not sufficient, to develop CD upon gluten dietary exposure' imply?

<p>Individuals must have the genetic predisposition and consume gluten to develop CD (D)</p> Signup and view all the answers

In the context of the article, what is the significance of MDPI staying neutral with regard to jurisdictional claims?

<p>It ensures that the publisher does not take sides on disputed territories that could affect the interpretation of data (D)</p> Signup and view all the answers

What did Low-Beer et al. initially observe in CD patients regarding gallbladder function?

<p>Absent or impaired gallbladder contraction after a fatty meal. (B)</p> Signup and view all the answers

The study of bile salt turn-over in CD patients by Low-Beer et al. revealed what phenomenon?

<p>Stagnation of bile in the biliary tree. (C)</p> Signup and view all the answers

What did Di Magno et al. indirectly suggest was impaired in CD patients after a meal?

<p>Secretion of cholecystokinin (CCK). (C)</p> Signup and view all the answers

What key observation did Low-Beer et al. make regarding CCK levels in CD patients compared to controls?

<p>An increase of CCK fasting levels and a non-significant rise of CCK levels after a meal. (D)</p> Signup and view all the answers

What method did Low-Beer et al. use to assess gallbladder response in conjunction with measuring plasma CCK kinetics?

<p>Radioisotope cholecystography. (A)</p> Signup and view all the answers

How did gallbladder emptying differ in CD patients compared to controls in the study by Low-Beer et al.?

<p>Gallbladder emptying was delayed. (A)</p> Signup and view all the answers

What is the significance of Low-Beer et al.'s work in understanding gallbladder dysfunction in CD patients?

<p>It demonstrated the role of impaired CCK kinetics and gallbladder response in CD. (D)</p> Signup and view all the answers

Based on the experimental study by Di Magno et al. and the work of Low-Beer et al., what is the proposed sequence of events leading to gallbladder dysfunction in CD patients?

<p>Impaired CCK secretion -&gt; delayed gallbladder emptying -&gt; bile stagnation. (A)</p> Signup and view all the answers

What does the analysis of available studies primarily suggest about the relationship between celiac disease (CD) and gallbladder function?

<p>Impaired CCK release into the bloodstream is more likely than reduced gallbladder sensitivity. (D)</p> Signup and view all the answers

What is the potential long-term consequence of untreated celiac disease (CD) with regards to gallbladder function?

<p>Gallstone disease and related complications in adulthood. (A)</p> Signup and view all the answers

A study analyzes duodenal biopsies from patients with celiac disease (CD) and healthy controls. What is the primary conclusion regarding CCK-producing cells, based on immuno-staining and mRNA expression analysis?

<p>Defective CCK release in CD patients is likely due to decreased CCK synthesis, mediated by reduced mRNA content, rather than a reduction in the number of CCK-producing cells. (A)</p> Signup and view all the answers

What correlation was observed between delayed celiac disease (CD) diagnosis and gallbladder ejection fraction (GBEF)?

<p>A significant negative correlation, where longer delays led to lower baseline GBEF. (B)</p> Signup and view all the answers

A researcher is investigating serum CCK8 concentrations in children with untreated celiac disease (uCD) after a fatty meal, using radioimmunoassay. How would one describe the expected CCK response in these patients compared to healthy controls?

<p>The expected CCK response would be poor in uCD patients, consistent with those having flat intestinal mucosa. (C)</p> Signup and view all the answers

In the context of celiac disease (CD) and gallbladder function, what is the effect of adherence to a gluten-free diet (GFD)?

<p>It can lead to the return of normal CCK cell function and improvement in GB motility. (C)</p> Signup and view all the answers

Two studies investigate CCK release in Celiac Disease (CD) patients. One analyzes duodenal biopsies via immunostaining and mRNA expression, while the other measures serum CCK8 concentration after a fatty meal. What is a key difference in methodology between these studies?

<p>One study focuses on the number of CCK-producing cells, while the other examines the functional release of CCK in response to a stimulus. (B)</p> Signup and view all the answers

In studies assessing enteroendocrine cells, what inconsistent findings have been reported regarding CCK-positive cells in untreated celiac disease (CD) patients?

<p>Some studies found an increased number of CCK-positive cells, while others found normal or non-significantly reduced numbers. (D)</p> Signup and view all the answers

Based on the presented information, what conclusion can be drawn about the cause of defective CCK release in Celiac Disease (CD) patients?

<p>Defective CCK release is likely multifactorial, involving both reduced CCK synthesis and impaired cellular function. (A)</p> Signup and view all the answers

A researcher aims to replicate the findings of Deprez et al. (2002b) regarding CCK in celiac disease. Which methodologies would be most appropriate?

<p>Performing immuno-staining and mRNA expression analysis on duodenal biopsies to assess CCK-producing cells. (A)</p> Signup and view all the answers

What was the main finding when comparing children with normal gallbladder ejection fraction (GBEF) to those with reduced GBEF in the subgroup analysis?

<p>Children with reduced GBEF had a significantly longer delay in diagnosis and slower OCTT. (B)</p> Signup and view all the answers

Consider two studies: Study A examines duodenal biopsies and Study B measures serum CCK after a fatty meal. If both studies involve children with untreated celiac disease (uCD), what confounding factor might disproportionately affect the results of Study B compared to Study A?

<p>Variations in fat digestion and absorption among individual children, influencing CCK release. (C)</p> Signup and view all the answers

Based on the information, what parameters are indicative of gallbladder dysmotility in children with celiac disease?

<p>Reduced GBEF and longer delay in diagnosis (B)</p> Signup and view all the answers

What statistical findings are reported concerning the delay in diagnosis and its impact on gallbladder function?

<p>A significant negative correlation with baseline GBEF, $r = -0.5$, $p &lt; 0.001$, and percentage postprandial GB volume change, $r = -0.3$, $p &lt; 0.01$. (B)</p> Signup and view all the answers

A new study aims to determine if a specific dietary intervention can improve CCK release in children with celiac disease. Based on the information provided in the text, which outcome would provide the STRONGEST evidence that the dietary intervention is effective?

<p>An increase in serum CCK8 concentration <em>after</em> a standardized meal, compared to pre-intervention levels. (A)</p> Signup and view all the answers

A researcher hypothesizes that the "flat intestinal mucosa" observed in some celiac disease patients directly impairs CCK release. Which of the following experimental approaches would be the MOST appropriate for testing this hypothesis in vitro?

<p>Measuring CCK release from cultured duodenal cells exposed to varying degrees of physical flattening <em>in vitro</em>. (C)</p> Signup and view all the answers

Which diagnostic finding is MOST indicative of chronic cholecystitis when using gallbladder scintigraphy?

<p>Abnormal gallbladder contraction (D)</p> Signup and view all the answers

A patient presents with recurrent biliary pain, nausea, and bloating. Ultrasonography reveals gallbladder wall thickening. Which condition should be considered in the differential diagnosis, especially if the patient also has celiac disease (CD)?

<p>Chronic cholecystitis (A)</p> Signup and view all the answers

What is a key limitation in understanding the relationship between dyspeptic symptoms, right upper abdominal pain, and gallbladder contractility in celiac disease (CD) patients?

<p>Absence of data correlating these symptoms with gallbladder contractility at the time of CD diagnosis. (C)</p> Signup and view all the answers

According to the 'UK biobank' study, what percentage of individuals with celiac disease (CD) were diagnosed with cholelithiasis?

<p>6.1% (A)</p> Signup and view all the answers

In the 'UK biobank' study, how did the rate of cholelithiasis in individuals with celiac disease (CD) compare to the control group?

<p>Significantly higher (C)</p> Signup and view all the answers

What is a primary challenge in diagnosing chronic cholecystitis?

<p>The variability and lack of clear definition in diagnostic criteria. (C)</p> Signup and view all the answers

How might coeliac disease contribute to the development of cholesterol gallstone disease?

<p>By impairing intestinal cholecystokinin secretion, reducing gallbladder emptying and promoting cholesterol crystal formation. (D)</p> Signup and view all the answers

Why might gallbladder dysfunction contribute to abdominal symptoms in patients with celiac disease (CD)?

<p>It often overlaps with (functional) recurrent abdominal pain and dyspeptic syndromes common in CD. (A)</p> Signup and view all the answers

What percentage of individuals with celiac disease (CD) were diagnosed with unspecified cholecystitis in the 'UK biobank' study?

<p>1.1% (D)</p> Signup and view all the answers

Which of the following is a potential complication of impaired gallbladder emptying?

<p>Increased risk of biliary sludge and gallstone formation. (D)</p> Signup and view all the answers

What could be a possible cause of acute acalculous cholecystitis in children, according to the text?

<p>Severe Epstein-Barr virus (EBV) hepatitis. (B)</p> Signup and view all the answers

In critically ill patients, impaired gallbladder emptying is assessed using which diagnostic method?

<p>3D Ultrasound. (C)</p> Signup and view all the answers

How does Peptide YY (PYY) affect gallbladder emptying in humans?

<p>It inhibits gallbladder emptying, slowing down the digestive process. (D)</p> Signup and view all the answers

Why might elderly patients with biopsy-defined coeliac disease present a diagnostic challenge?

<p>They may present with atypical or non-specific symptoms, complicating diagnosis. (C)</p> Signup and view all the answers

What is the significance of age at diagnosis in the nutritional course of coeliac disease?

<p>Later diagnosis may lead to prolonged exposure to gluten and increased risk of nutritional deficiencies. (D)</p> Signup and view all the answers

What is the likely connection between critical illness and impaired gallbladder emptying?

<p>Critical illness is associated with physiological stress and altered gastrointestinal motility, impacting gallbladder function. (A)</p> Signup and view all the answers

Flashcards

ref.

Abbreviation for reference number.

n

Abbreviation for number.

yrs.

Abbreviation for years.

Y

Indicates 'yes'.

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N

Indicates 'no'.

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n/a

Abbreviation for not available.

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N/A

Abbreviation for not applicable.

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M

Abbreviation for mean (average).

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Celiac Disease (CD)

An immune-mediated disorder triggered by gluten intake in genetically predisposed individuals.

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Genetic Predisposition in CD

Specific genetic HLA-DQ variants are necessary but not sufficient to develop CD upon gluten exposure.

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Key HLA-DQB1 Alleles in CD

HLA-DQB102 and HLA-DQB10302 are the most relevant alleles.

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Gallbladder Impairment in CD

Many CD patients experience impaired gallbladder function.

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Gallbladder Complications in CD

CD patients don't seem more predisposed to gallbladder complications.

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Need for Clinical Studies

Specific clinical studies are needed for a better understanding of the clinical implications of gallbladder alterations in CD patients.

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Reversibility with Diet

The condition appears to be reversible with a gluten-free diet in most cases.

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Improvements in CD Diagnosis

Substantial improvements in CD diagnosis have reduced the diagnostic delay and potential clinical consequences of CD-related gallbladder dysfunction.

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What is CCK?

Cholecystokinin (CCK) is a hormone that stimulates the digestion of fat and protein.

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What is Immuno-staining?

A technique that uses antibodies to detect specific substances in cells/tissues.

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What is uCD?

uCD refers to untreated Celiac Disease.

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What is gfdCD?

gfdCD refers to Celiac Disease patients on a gluten-free diet.

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What are IELs?

IELs are immune cells found in the lining of the small intestine.

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What is mRNA expression?

mRNA expression is how much a gene is 'turned on' to make a protein.

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What is Radioimmunoassay?

A test that measures the amount of a substance using antibodies and radioactivity.

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What is CMPE?

CMPE stands for cow's milk protein enteropathy.

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Chronic Cholecystitis

A long-lasting inflammation of the gallbladder with variable and poorly defined diagnostic criteria.

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Symptoms of Chronic Cholecystitis

Includes recurrent biliary pain (colic to vague discomfort), nausea, reflux, and bloating.

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Ultrasound Findings in Chronic Cholecystitis

Unspecific findings may include cholelithiasis (gallstones) and gallbladder wall thickening.

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Gallbladder Scintigraphy in Chronic Cholecystitis

Demonstrates abnormal contraction and reduced ejection fraction.

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Gallbladder Ejection Fraction Impact

Impaired/reduced gallbladder emptying

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Overlap of Gallbladder Dysfunction

Gallbladder dysfunction overlaps with recurrent abdominal pain and dyspeptic syndromes, common in CD patients.

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Cholelithiasis Incidence in CD

CD patients have a higher incidence of gallstones compared to controls.

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What is the 'UK biobank' (UKB)?

Population-based cohort study in the United Kingdom from 2006 to 2010.

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GB dysmotility in CD

Gallbladder dysmotility can occur in children with celiac disease, especially if diagnosis is delayed.

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Reversing GB dysmotility

Adherence to a gluten-free diet (GFD) can reverse gallbladder (GB) dysmotility in children with celiac disease.

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Untreated CD & Gallstones

GB hypomotility may lead to gallstone disease and related complications in adulthood if celiac disease is left untreated.

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Delayed CD Diagnosis & GBEF

Delay in diagnosis of celiac disease negatively correlates with baseline gallbladder ejection fraction (GBEF).

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CCK Release in CD

Studies suggest impaired CCK release into the bloodstream is a primary issue in celiac disease rather than reduced GB sensitivity to CCK.

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CCK-Positive Cells & CD

Some studies have found an increased number of CCK-positive cells in untreated CD patients.

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Normal CCK cells in CD.

Other studies found similar number of CCK-positive cells in CD patients when compared to normal ranges.

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GFD and gall bladder motility

Following a gluten free diet can lead to normal CCK cell function and improved gallbladder motility.

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Peptide YY & Gallbladder

Peptide YY affects gallbladder emptying.

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CCK Secretion in CD

Reduced intestinal secretion of cholecystokinin (CCK)

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CD Epidemiology

May be increasing, but could also be due to increased testing.

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CD Diagnosis Age

The age at diagnosis is changing.

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CD in Asia

Varies, with diagnostic barriers in some regions.

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CD and Cholecystitis

Acalculous cholecystitis is a possible presentation.

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Gallstones in CD Children

Gallstones may be more frequent.

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Gallbladder Emptying in Critical Illness

Impaired gallbladder emptying can occur in critically ill patients.

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Study Notes

  • Celiac Disease (CD) is an immune-mediated disorder primarily affecting the small intestine, with potential impact on extra-intestinal organs, including liver and biliary tract.

Gallbladder Dysfunction in CD

  • This review analyzes the pathophysiology and clinical evidence of gallbladder dysfunction in CD, focusing on potential complications and research gaps.
  • CD patients may experience perturbations in bile composition and gallbladder dysmotility, mainly impaired emptying during digestion.
  • A key factor is a perturbation of cholecystokinin secretion by duodenal enteroendocrine cells due to nutrient stimulation.
  • Gluten-free diets appear to reverse this situation in most cases.
  • CD patients don't show an increased predisposition to gallbladder complications like calculous and acalculous cholecystitis.
  • Limited clinical studies have focused on these aspects, with recent improvements in CD diagnosis and treatment potentially reducing the impact of gallbladder dysfunction.
  • There is a need for focused clinical studies for a comprehensive understanding of gallbladder alterations in CD.

Introduction to CD

  • CD is triggered by gluten intake in genetically predisposed individuals with specific HLA-DQ variants, mainly MHC-DQ2 and/or MHC-DQ8 heterodimers.
  • HLA-DQB1 alleles, particularly HLA-DQB102 and HLA-DQB10302, are most relevant for CD predisposition, though genetic background alone is insufficient.
  • Additional factors like epigenetics and environment, greatly contribute to CD etiopathogenesis.
  • The hallmark of CD is gluten-sensitive enteropathy, characterized by intraepithelial lymphocyte infiltration and villous atrophy in the small intestine.
  • Liver is one of the most frequently affected extra-intestinal targets in CD, and unexplained hypertransaminasemia with non-specific histologic hepatic changes is the most common hepatic presentation of CD.
  • Besides the liver, the biliary tract can also be affected in CD patients, causing changes in gallbladder function.

Gallbladder Anatomy and Function

  • The gallbladder concentrates bile, adjusting its composition by absorbing water, sodium, cholesterol, phospholipids, and hydrophilic proteins and secreting mucins, hydrogen/chloride ions, immunoglobulins, and calcium.
  • Bile acids in the gallbladder bile have a greater concentration than in hepatic bile.
  • Synthesized from cholesterol in the liver, bile acids are conjugated to taurine or glycine for increased solubility, then concentrated and stored in the gallbladder.
  • The gallbladder consists of the fundus, corpus, and infundibulum, ending in the cystic duct that joins the common bile duct without a sphincter.
  • The common bile duct merges with the pancreatic duct, forming the ampulla of Vater which opens into the duodenal lumen with the sphincter of Oddi.
  • Innervated by vagal and splanchnic nerves, the gallbladder is functionally integrated with the digestive tract through neuro-hormonal mechanisms.
  • Bile flows through passive and active means during fasting, with adrenergic and non-adrenergic fibers facilitating relaxation for bile reception.
  • Contractions during the cephalic, antral, and intestinal phases are due to the nerves and gut hormone cholecystokinin (CCK), while the Sphincter of Oddi relaxes.
  • Cephalic and antral gallbladder emptying is nervouse mediated, while intestinal phase relies on CCK action.

CCK Production and Function

  • CCK hormone is produced by I-cells of the intestinal mucosa, which have a close proximity to the intestinal lumen, enabling for efficient sensing.
  • Luminal content, especially food rich in protein and fat, highly effects and stimulates CCK release .
  • CCK secretory granules in the basal cell region contain a mixture of molecular forms; CCK-33 is predominant in the human intestine and circulation.
  • By interacting with receptors, CCK peptides stimulate the target cells.
  • CCK1 receptors mediate gallbladder contraction and relaxation of the sphincter of Oddi, along with hepatic bile, pancreatic enzyme secretion, growth, and inhibition of gastric acid secretion and emptying.
  • CCK2 receptors are mainly in the brain.

Gallbladder Functioning and Regulation in CD

  • CD's hallmark is the damage and flattening of the jejunal/ileal mucosa, potentially impairing endocrine cells.
  • Intestinal injury from CD can impair digestion and absorption, directly by enterocyte damage and villous architecture disruption, and indirectly, by disrupting the production and secretion of gut hormones and peptides that regulate gut motility and organs involved in digestion like the exocrine pancreas and gallbladder.
  • Increased bile flow rate and biliary secretion of components like cholesterol, phospholipids, and bile acids reported in active CD, return to normal under GFD.
  • Cholesterol secretion into bile is linked to a decrease in serum cholesterol in CD, observed in both children and adults.

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