Gastro Flash Vol-4, No-3, 2018

Celiac disease (CD), also known as “celiac sprue”, is a chronic inflammatory disorder of the small intestine resulting from both environmental (gluten) and genetic factors (human leukocyte antigen (HLA) and non-HLA genes).1,2 This autoimmune disorder originates by an aberrant adaptive immune response produced by ingestion of dietary gluten products in the genetically susceptible individuals worldwide.1 The prevalence rate of CD ranges from about 0.5-1% being more prevalent in patients with diabetes, autoimmune disorders or relatives of patients with CD as they are at a higher risk of shared HLA typing.2 The clinical presentation of CD varies with age and is manifested by gastrointestinal, extraintestinal or no signs of symptoms at all as listed in table 1.3 The pathophysiology of CD is unique from other autoimmune diseases and occurs due to genetic predisposition (either HLA- DQ2 or HLA-DQ8), presence of well defined precipitating factor (gluten), and existence of highly sensitive and specific auto- antibodies against the naturally occurring human enzyme, tissue transglutaminase (TG2).3,4 The process initiates due to the presence of gluten, an alcohol-soluble fraction of wheat protein, which is consumed in large quantities (10–20 g per day) as part of the normal food intake. However, some of these gluten peptides do not get degraded by the gastrointestinal enzymes but are instead taken up across the epithelium of the small- bowel mucosa. In the small bowel mucosa these gluten peptides are presented on the antigen-presenting cells of people with the HLA types HLA-DQ2 or HLA-DQ8 (about 90% and 10% of persons with celiac disease, respectively) thereby causing stimulation of gluten-specific T cells (Figure 1).4 Hence, the diagnosis of CD is suggested by the presence of TG auto-antibodies but is established by biopsy of the small intestine by upper intestinal endoscopy.

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure providing radiological visualization of detailed structure and pathological changes in the biliary tree and pancreatic ducts. This widely used accurate imaging modality is usually carried out by injecting contrast agent into the common bile duct (CBD) and the main pancreatic duct (MPD) through papilla located in second part of duodenum, for diagnosing the pancreatobiliary diseases. It is used in an array of conditions as listed in box 1.