Malabsorption in Coeliac Sprue

1. Introduction.- 1.1 History.- 1.2 Terminology.- 1.3 Definition of coeliac sprue.- 1.4 Incidence.- 2. Pathogenesis of Coeliac Sprue.- 2.1 Introduction.- 2.2 Causative factor.- 2.3 Pathogenesis.- 2.3.1 Peptidase deficiency theory.- 2.3.2 Immunological theory.- 2.3.3 Other theories.- 3. Morphology of the Small Intestine Under Normal Conditions and in Coeliac Sprue.- 3.1 General introduction.- 3.2 The normal small intestine.- 3.2.1 Macroscopic anatomy.- 3.2.2 Stereomicroscopic aspect of the mucosa.- 3.2.3 Microscopic morphology of the mucosa.- 3.2.4 Ultrastructure of the enterocyte.- 3.3 The small intestine in coeliac sprue.- 3.3.1 Macroscopic anatomy.- 3.3.2 Stereomicroscopic aspect of the mucosa.- 3.3.3 Microscopic morphology of the mucosa.- 3.3.4 Ultrastructure of the enterocyte.- 3.4 Morphogenesis of the coeliac mucosa.- 3.5 Morphometry of the mucosa.- 4. Physiology of the Small Intestine.- 4.1 General introduction.- 4.2 Motility.- 4.3 Innervation.- 4.4 Circulation.- 4.5 Lymphatic system.- 4.6 Digestive secretions.- 4.6.1 Introduction.- 4.6.2 Gastric secretion.- 4.6.3 Pancreatic secretion.- 4.6.4 Bile secretion.- 4.7 Intestinal hormones.- 4.8 Intestinal mucus.- 4.9 Exfoliation of enterocytes.- 4.10 Enteric plasma protein loss.- 4.11 Intestinal flora.- 5. Intestinal Digestion and Absorption.- 5.1 General introduction.- 5.1.1 Surface.- 5.1.2 Mucosal contact time.- 5.1.3 Digestion.- 5.1.4 Translocation.- 5.1.5 Unstirred layer.- 5.1.6 Absorption.- 5.1.7 Secretion.- 5.2 Water and electrolytes.- 5.3 Carbohydrate.- 5.4 Fat.- 5.4.1 Introduction.- 5.4.2 Triglycerides.- 5.4.3 Cholesterol.- 5.4.4 Phospholipids.- 5.4.5 Fat-soluble vitamins.- 5.4.5.1 Introduction.- 5.4.5.2 Vitamin A.- 5.4.5.3 Vitamin D.- 5.4.5.4. Vitamin E.- 5.4.5.5 Vitamin K.- 5.5 Protein.- 5.6 Calcium.- 5.7 Magnesium.- 5.8 Haematopoietic factors.- 5.8.1 Iron.- 5.8.2 Vitamin B 12.- 5.8.3 Folates.- 5.9 Water-soluble vitamins.- 5.9.1 Vitamin C.- 5.9.2 Thiamine.- 5.9.3 Riboflavin.- 5.9.4 Niacin.- 5.9.5 Vitamin B6.- 5.9.6 Pantothenic acid.- 6. Pathophysiology of Coeliac Sprue.- 6.0 Introduction.- 6.1 Composition of the group of patients studied.- 6.2 Motility.- 6.3 Innervation.- 6.4 Circulation.- 6.5 Lymphatic system.- 6.5.1 Introduction.- 6.5.2 Protein leakage and lymphocyte count.- 6.5.3 Influence of restriction of LCT fat on protein leakage.- 6.5.4 Abnormalities of the mesenteric lymph nodes.- 6.5.5 Comment.- 6.6 Digestive secretions.- 6.6.1 Introduction.- 6.6.2 Gastric secretion.- 6.6.3 Pancreatic secretion.- 6.6.4 Comment.- 6.7 Intestinal hormones.- 6.8 Intestinal mucus.- 6.9 Exfoliation of enterocytes.- 6.10 Enteric plasma protein loss.- 6.10.1 Introduction.- 6.10.2 Determination of enteric protein loss.- 6.10.3 Comment.- 6.11 Intestinal flora.- 6.11.1 Introduction.- 6.11.2 Culture of intestinal fluid.- 6.11.3 ‘Breath’ test with 14C-glycocholic acid.- 6.11.4 Urinary indican excretion.- 6.11.5 Effect of the gluten-free diet.- 6.11.6 Comment.- 6.11.7 Conclusions.- 7. Malabsorption in Coeliac Sprue.- 7.1 Introduction.- 7.2 Water and electrolytes.- 7.3 Carbohydrate.- 7.3.1 Introduction.- 7.3.2 Microscopic examination of faeces for starch.- 7.3.3 Glucose tolerance test.- 7.3.4 Lactose tolerance test.- 7.3.5 Lactase activity of the jejunal mucosa.- 7.3.6 Tolerance tests with other dis-accharides.- 7.3.7 D-xylose test.- 7.3.8 Effect of the gluten-free diet.- 7.3.9 Comment.- 7.3.10 Conclusions.- 7.4 Fat.- 7.4.1 Introduction.- 7.4.2 Fat absorption coefficient.- 7.4.3 Serum cholesterol concentration.- 7.4.4 Serum vitamin A concentration.- 7.4.5 Vitamin A tolerance test.- 7.4.6 Serum vitamin E concentration.- 7.4.7 Thrombotest.- 7.4.8 Effect of the gluten-free diet.- 7.4.9 Comment.- 7.4.10 Conclusions.- 7.5 Protein.- 7.5.1 Introduction.- 7.5.2 Serum albumin concentration.- 7.5.3 Enteric protein loss.- 7.5.4 Albumin synthesis.- 7.5.5 Effect of the gluten-free diet.- 7.5.6 Comment.- 7.5.7 Conclusions.- 7.6 Calcium.- 7.6.1 Introduction.- 7.6.2 Plasma calcium concentration.- 7.6.3 Calcium absorption.- 7.6.4 Alkaline phosphatase activity.- 7.6.5 Hydroxyproline excretion.- 7.6.6 Histological examination of bone tissue.- 7.6.7 Two-hour phosphate clearance.- 7.6.8 Radiographs of the hand skeleton.- 7.6.9 Amino-aciduria study.- 7.6.10 Effect of the gluten-free diet.- 7.6.11 Comment.- 7.6.12 Conclusions.- 7.7 Magnesium.- 7.7.1 Introduction.- 7.7.2 Serum magnesium concentration.- 7.7.3 Effect of the gluten-free diet.- 7.7.4 Comment.- 7.7.5 Conclusions.- 7.8 Haematopoietic factors.- 7.8.1 Iron.- 7.8.1.1 Introduction.- 7.8.1.2 Haemoglobin concentration.- 7.8.1.3 Bone marrow study.- 7.8.1.4 Serum iron concentration.- 7.8.1.5 Iron absorption.- 7.8.1.6 Effect of the gluten-free diet.- 7.8.1.7 Comment.- 7.8.1.8 Conclusions.- 7.8.2 Vitamin B 12.- 7.8.2.1 Introduction.- 7.8.2.2 Serum vitamin B12 concentration.- 7.8.2.3 Vitamin B12 absorption.- 7.8.2.4 Effect of the gluten-free diet.- 7.8.2.5 Comment.- 7.8.2.6 Conclusions.- 7.8.3 Folates.- 7.8.3.1 Introduction.- 7.8.3.2 Serum folate concentration.- 7.8.3.3 Effect of the gluten-free diet.- 7.8.3.4 Comment.- 7.8.3.5 Conclusions.- 7.9 Water-soluble vitamins.- 7.9.0 Introduction.- 7.9.1 Vitamin C.- 7.9.2 Thiamine.- 7.9.3 Riboflavin.- 7.9.4 Niacin.- 7.9.5 Vitamin B6.- 7.9.6 Pantothenic acid.- 8. Clinical Features.- 8.1 Introduction.- 8.2 Incidence of the various symptoms.- 8.3 General complaints and symptoms.- 8.4 Gastrointestinal tract.- 8.5 Haematopoiesis and blood coagulation.- 8.6 Musculoskeletal system.- 8.7 Skin, hair and nails.- 8.8 Reproductive functions.- 8.9 Nervous system.- 8.10 Psyche.- 9. Clinical Course and Response to Treatment.- 9.1 Spontaneous course.- 9.2 Treatment by the gluten-free diet.- 9.2.1 Nature of the diet.- 9.2.2 Adherence to the diet.- 9.2.3 Effect on clinical symptoms.- 9.2.4 Effect on biochemical parameters.- 9.2.5 Effect on mucosal morphology.- 9.3 Additional measures.- 9.3.1 Further dietary restrictions.- 9.3.2 Replacement therapy.- 9.3.3 Parenteral feeding.- 9.3.4 Administration of glucocorticosteroids.- 9.4 Complications.- 9.4.1 Introduction.- 9.4.2 Abnormal bacterial flora.- 9.4.3 Other complications.- 9.4.4 Malignant degeneration and malignancies.- 9.5 Conclusions.- 10. Association with Other Diseases.- 10.1 Introduction.- 10.2 Dermatitis herpetiformis.- 10.2.1 Personal observations.- 10.2.2 Comment.- 10.3 Concomitant diseases.- 10.3.1 Personal observations.- 10.3.2 Comment.- 11. Special Forms of Sprue.- 11.1 Introduction.- 11.2 Ulcerative duodenojejunoileitis.- 11.2.1 Introduction.- 11.2.2 Personal observations.- 11.2.3 Comment.- 11.3 ‘Collagenous’sprue.- 11.3.1 Introduction.- 11.3.2 Personal observations.- 11.3.3 Comment.- 11.4 Refractory sprue.- 11.4.1 Introduction.- 11.4.2 Personal observations.- 11.4.3 Comment.- 12. Methods and Procedures.- 12.1 Biochemical assays.- 12.1.1 Determinations in blood.- 12.1.2 Determinations in urine.- 12.1.3 Absorption tests.- 12.1.4 Other determinations.- 12.2 Statistical analysis.- 12.2.1 Calculation of normal values.- 12.2.2 Calculation of significances.- 12.3 Biopsy of the small intestine.- References.- Survey of References to Patients.