J Clin Pathol 1992;45:597-600 597 serology in patients with and dermatitis herpetiformis J Clin Pathol: first published as 10.1136/jcp.45.7.597 on 1 July 1992. Downloaded from J E Crabtree, S O'Mahony, J I Wyatt, R V Heatley, J P Vestey, P D Howdle, B J Rathbone, M S Losowsky

Abstract some have found little evidence to support this Aims: To investigate whether Helicobacter in coeliac disease8 and other abnormalities pylori infection or autoimmune including those of lymphocytic gastritis have is responsible for the reported increase in also been reported.9 10 gastric pathology and abnormalities of Helicobacter pylon is now recognised to be a gastric function in patients with coeliac major aetiological factor in most patients with disease and dermatitis herpetiformis non-autoimmune chronic gastritis. l In (DH). patients with pernicious anaemia, however, it is Methods: Serum H pylori IgG antibodies rare to find H pylori infection on histological were assayed by enzyme linked immuno- examination, suggesting that in this condition sorbent assay and anti- the may be resistant to colon- bodies by radioimmunoassay in 99 isation. 13 Seropositivity for Hpylori is rare in patients with coeliac disease and 58 pernicious anaemia.'3 In contrast, subjects patients with dermatitis herpetiformis with non-autoimmune gastritis have a high from two geographic areas. level of seropositivity for Hpylori, although the Results: H pylori positivity in patients bacteria may be undetectable in biopsy speci- with coeliac disease and dermatitis herpe- mens from patients with advanced atrophy of tiformis increased with age, reaching 50%/O the acid secreting corpus mucosa.'4 and 70%, respectively, in patients over 50 In this study we examined serum samples of years. The percentage H pylori seroposi- patients with coeliac disease and dermatitis tivity in coeliac disease did not differ from herpetiformis for H pylori IgG antibodies and the percentage positivity observed in 250 intrinsic factor antibodies in an attempt to similarly aged blood donors from the establish the aetiology of the chronic gastritis same geographic area (Leeds). Seroposi- reported in these patients. tivity in patients with dermatitis herpeti- formis was not significantly different from http://jcp.bmj.com/ the level of positivity observed in 98 age Methods matched patients without dermatitis her- Ninety nine patients with coeliac disease petiformis attending the same Edinburgh (mean (SD) age 40 9 (16-6), range 15-72 dermatology clinic. Only one patient with years) were studied. All had peripheral blood coeliac disease had positive intrinsic fac- samples taken while undergoing jejunal biopsy. tor antibodies. H pylon seropositivity in Twenty seven patients were untreated (mean Edinburgh control subjects under 30 years age 39 3 (16-3) years), with histological sub- on September 27, 2021 by guest. Protected copyright. of age (41.90/6) was significantly higher total villous atrophy. Twenty five of these (p < 0.03) than in Leeds controls (18%) of patients subsequently improved histologically corresponding age. An increasing preva- once gluten had been excluded from the diet. lence ofHpyloni seropositivity with age in Two have yet to be rebiopsied. Seventy two Department of coeliac disease and dermatitis her- patients (mean age 41e1 (16-8) years) had been Medicine, St James's University Hospital, petiformis paralleled that of the control on a gluten free diet for at least six months at Leeds LS9 7TF groups. the time of investigation. Histologically, these J E Crabtree Conclusions: Gastritis in coeliac disease subjects either had normal jejunal biopsy RV Heatley P D Howdle and dermatitis herpetiformis is largely specimens or partial villous atrophy. Serum B J Rathbone caused by Hpyloni infection at a level that was stored at - 20°C until assayed. Control M S Losowsky is no different from that of the general serum samples were obtained from 250 blood Department of population. Any increase in the preva- donors (age range 18-64 years) from the same Pathology, St James's lence of in these two diseases area as the with coeliac University Hospital, gastritis geographic patients Leeds might be caused by lymphocytic gastritis disease. J I Wyatt rather than pernicious anaemia. Fifty eight patients with dermatitis her- Gastrointestinal Unit, petiformis (mean age 51-5 (16-7), range Western General 14-79) were studied. All had blood samples Hospital, Edinburgh S O'Mahony Both coeliac disease and dermatitis her- taken while undergoing jejunal biopsy and is associated with serum was stored at - These Department of petiformis (which frequently 70°C. patients Dermatology, Royal coeliac disease) have been reported to be come from a different regional location (Edin- Infirmary, Edinburgh associated with abnormalities of gastric histo- burgh) to the patients with coelic disease and J P Vestey logy and gastric function.1-7 Changes of blood donors (Leeds). As regional variations in Correspondence to: atrophic gastritis with an increased prevalence H pylon seropositivity are known to occur, 5 16 Dr J E Crabtree of cell antibodies seem to be in the with dermatitis Accepted for publication parietal partic- seropositivity patients 20 November 1991 ularly common in several studies,2 although herpetiformis was compared with that in 98 598 Crabtree, O'Mahony, Wyatt, Heatley, Vestey, Howdle, Rathbone, Losowsky

80 r were assayed using a solid phase 57Co radio- Controls immunoassay (Diagnostic Products Corpora- I Coeliac disease tion, Los Angeles, USA) according to the 0 60 manufacturer's instructions. 0. J Clin Pathol: first published as 10.1136/jcp.45.7.597 on 1 July 1992. Downloaded from 0r n=40 n=31 Statistical analyses were carried out using 0 the Yates's corrected x2 and Fisher's exact 0 tests, as appropriate. 0 40 0 n = 144 0 n =38 0 Results n =66 n =30 t// 0 201- The percentage seropositivity for H pylori in patients with coeliac disease and the blood donor controls in relation to age is shown in fig

I LO'xf .X r vfA 0 1. Overall, 29% ofpatients with coeliac disease <30 30-49 >50 and 30% of the blood donors were H pylori Age seropositive, with the percentage increasing with age in both groups. Forty eight per cent of Figure I Percentage H pylori seropositivity in patients with coeliac disease and blood donors in relation to age. patients with coeliac disease over the age of 50 were seropositive. The percentage seropositiv- ity was not significantly different from that of 80 Controls the blood donor controls for any age group. H E23 Dermatitis n 44n=3 pylori seropositivity was higher in patients with untreated coeliac disease (39%) than in treated subjects (25%) despite the group having sim- ilar mean ages. Under 30 years of age, sero- 10-n=31 n=7n=1 positivity in untreated patients was 40% com- 0 pared with 5% in subjects on a gluten free diet 40 n 23 (p < 0-04; Fisher's exact test) (table), but no significant differences between treated and <30 3>4n 1 Fiue ecetgeHploiseooitvtyidrattsherpetiformisanatetswt untreated patients were apparent in subjects CL between 30-49 and over 50 years (table). The percentage seropositivity for Hpylori in patients with dermatitis herpetiformis and the control subjects with other dermatological o~ ~ ~ ~~cii7h a aiu nlm aoysi conditions in relation to age is shown in fig 2. Age Overall, 63-5% of patients with dermatitis herpetiformis and 53% of the control group Figure 2 Percentage H pylon seropositivity in patients with dermatitis herpetformis and were seropositive. Under 30 years of age, http://jcp.bmj.com/ control subjects with other dermatolical conditions in relation to age. 41-9% of patients with dermatitis her- petiformis were seropositive, rising to 70% in those over 50 years of age. The percentage years)1Th attn dinge std ofa uta patients (mean age45t3 (20u3), age range seropositivity in those under 30, 30-49, and 15-95 yer)atnigtesame dermatology over 50 years was not significantly different clinic who had various inflammatory skin from the control group of patients from the on September 27, 2021 by guest. Protected copyright. disorders but no history of dermatitis herpe- same dermatology clinic, who showed similar tiformis. high levels of seropositivity. The 41-9% sero- Serum samples were assayed for H pylori positivity in Edinburgh controls under 30 years IgG antibodies by ELISA, as previously descri- of age was significantly higher (p < 0 03) than bed.'7 The antigen consisted of an ultra- Leeds controls of corresponding age (18%). centrifuged sonicated preparation from one Intrinsic factor blocking antibodies were pylori.strain of H Positive and negative con- found only in one patient with coeliac disease; trols were assayed on each plate. The cutoff for this patient was seronegative for Hpylori. None positivity was determined using serum from of the patients with dermatitis herpetiformis 116 patients with known H pylori infection. had intrinsic factor antibodies. Assay specificity and sensitivity were, respec- tively, 97% and 95%. Previous studies have shown the specificity of the ELISA for H Discussion pylon'8 . Gastric infection with H pylori is now recog- Serum intrinsic factor blocking antibodies nised as the aetiological agent in over 90% of cases of chronic gastritis." Because previous studies had suggested an increase in chronic H pylori seropositivity in patients with untreated and treated coeliac disease gastritis in patients with coeliac disease and -6 Untreated Treated dermatitis herpetiformis,' we expected to find a high prevalence of Hpyloi among these H pylori H pylori groups. No increase in H pylori seropositivity Age Positive Negative Positie Negative was evident in either coeliac disease or derma- titis either that the <30 4* (40%) 6 1 (5%) 19 herpetiformis, suggesting 30-49 3 (30%) 7 6 (21%) 22 prevalence of chronic gastritis is not higher in >50 4 (50%) 4 11 (48%) 12 coeliac disease and dermatitis herpetiformis, or *p < 0-04 Fisher's exact test. that Hpylori negative forms of chronic gastritis H pylori serology in patients with coeliac disease and dermatitis herpetiformis 599

(such as autoimmune gastritis or lymphocytic low,29 30 these changes would be expected to be gastritis) account for the higher proportion of more effective in younger subjects. It is intrigu- gastritis among these patients. ing to speculate whether, in this special situa-

The high prevalence of H pylori infection in tion, the decreased prevalence of seropositivity J Clin Pathol: first published as 10.1136/jcp.45.7.597 on 1 July 1992. Downloaded from the general population makes selection of in young treated patients may follow resolution controls important. The increasing prevalence of infection. Whereas natural infection with H of H pylori with increasing age in asymptomtic pylori results in chronic gastritis,20 self limiting, subjects is well recognised.'9 More recently, acute infection has also been described.3' geographical variations in prevalence within Existing data regarding the prevalence and the same country have been documented'6 and type of gastritis in coeliac disease and dermati- this is confirmed in our study where the tis herpetiformis conflict. Our serological study prevalence of H pylori was significantly higher shows that the prevalence of H pylori infection in the control group from Edinburgh than is the same in these patients as controls and from Leeds. The source of the control groups, that autoimmune gastritis is uncommon. Gas- however, differed. The importance of age and tric pathology in this group of patients there- geographic factors in relation to gastritis may fore requires re-evaluation in the light ofrecent not have been recognised in previous studies developments in our understanding of chronic which claimed an increased prevalence of gastritis. gastritis in coeliac disease and dermatitis her- We conclude that gastritis in coeliac disease petiformis. and dermatitis herpetiformis is largely caused Previous studies, including acid secretion by H pylori infection and that this is no and autoantibody measurements, suggest that different to the level in the general population. autoimmune gastritis with atrophy may be Any increase in the prevalence of gastritis in more common in patients with dermatitis coeliac disease and dermatitis herpetiformis is herpetiformis.2`6 However, using intrinsic fac- unlikely to be due to pernicious anaemia, but tor antibodies as a marker for autoimmune could be partly accounted for by lymphocytic gastritis, we found no evidence for this. As not gastritis. all patients with autoimmune gastritis will have This study was carried out with financial support from the instrinsic factor antibodies, a proportion of Yorkshire Regional Health Authority. We thank Dr D S patients with autoimmune mediated gastritis in Tompkins for providing the H pylori strain used in the ELISA; coeliac Dr A Manning, Dr J Findlay, and the staff of the Gastro- disease and dermatitis herpetiformis enterology Department of Bradford Royal Infirmary, for their may not have been detected. Impaired gastric cooperation; and Miss A Batty for technical assistance. acid secretion may also be found in Helicobac- 1 Hansky J, Shiner M. Gastric studies in idiopathic steator- ter associated gastritis, both in the early stages rhea. 1963;45:49-56. 2 Gillberg R, Kastrup W, Mobacken H, Stockbrugger R, of the infection20 and in association with Ahren C. Gastric morphology and function in dermatitis atrophic changes in the corpus mucosa in herpetiformis and in coeliac disease. ScandJ Gastroenterol (presumably) longstanding infection. '4Thus H 1985;20: 133-40. 3 O'Donoghue DP, Lancaster-Smith M, Johnson GD, Kumar http://jcp.bmj.com/ pylorn infection offers an alternative explana- PJ. Gastric lesion in dermatitis herpetiformis. Gut tion for 1976;17: 185-8. the hypochlorhydria previously ob- 4 Primignani M, Agape D, Ronchi G, et al. Gastric histology served in dermatitis herpetiformis and coeliac and function tests in Italian patients with dermatitis herpetiformis. Scand J Gastroenterol 1990;25:357-62. disease. It is interesting to speculate that the 5 KastrupW, Mobacken H, Stockbrugger R, Swolin B,Westin enhanced mucosal immunological responses in J. of in dermatitis herpeti- formis and its association with pernicious anaemia. Acta dermatitis herpetiformis2' 22 and coeliac dis- Med Scand 1986;220:261-8. 24 6 Mobacken H. ease23 may predispose infected subjects to Stockbrugger R, Kastrup W, Lundquist G, on September 27, 2021 by guest. Protected copyright. Development ofgastric dysfunction in dermatitis herpeti- more rapid development of atrophic gastritis formis. Acta Derm Venereol (Stockh) 1978;158:343-48. and associated changes in gastric physiology. 7 Gawkrodger DJ, McDonald C, O'Mahony S, Ferguson A. Small intestinal function and dietary status in dermatitis Lymphocytic gastritis, a pattern of mucosal herpetiformis. Gut 1991;32:377-82. that is characterised by the pres- 8 Lancaster-Smith MJ, Perrin J, Swarbrick ET, Wright JT. ence of Coeliac disease and . Postgrad Med J numerous intraepithelial T cells,25 has 1974;50:45-8. recently been observed in patients with untrea- 9 Wobler R, Owen D, DelBruno L, Appelman H, Freeman H. ted Lymphocytic gastritis in patients with celiac sprue or coeliac disease.9 It is currently unclear spruelike intestinal disease. Gastroenterology 1990; whether this gastritis9 is a gastric manifestation 98:310-15. of a 10 Karttunen T, Niemela S. Lymphocytic gastritis and coeliac gluten sensitive analogous to disease. J Clin Pathol 1990;43:436-7. the increase in intraepithelial lymphocyte den- 11 Dixon MF. Campylobacter pylori and chronic gastritis. In: in Rathbone BJ, Heatley RV, eds. Campylobacter pylori and sity the small intestine26 and in rectal gastroduodenal disease. Oxford: Blackwell Scientific Pub- mucosa as a response to the topical application lications, 1989:106-16. of 12 Flejou JF, Bahame P, Smith AC, Stockbrugger RW, Rode J, gluten.27 However, the introduction of a Price AB. Pernicious anaemia and Campylobacter like gluten free diet in patients with dermatitis organisms; is the gastric antrum resistant to colonisation? did not Gut 1989;30:60-4. herpetiformis change gastric morphol- 13 Fong TL, Dooley CP, Dehesa M, et al. Helicobacter pylori ogy, acid secretion, serum concentra- infection in pernicious anemia: a prospective controlled tions or study. Gastroenterology 1991;100:328-32. titres of antibodies,28 14 Karnes WE, Samloff IM, Siurala M, et al. Positive serum suggesting that the gastric abnormalities were antibody and negative tissue staining for Helicobacter pylori in subjects with atrophic body gastritis. Gastroen- not related to gluten. terology 1991;101:167-74. The increased H pylonr seropositivity in 15 Megraud F, Brassens-Rabbe MP, Denis F, Belbouri A, Hoa untreated coeliac DQ. Seroepidemiology of Campylobacter pylori infection patients under 30 years of in various populations. 7 Clin Microbiol 1989;27:1870-3. age may be related to known defects in 16 Hill MJ. H pylori carriage in patients with intestinal metaplasia and in endoscopical-proven normal controls. immunity of which one factor is hypo- Rev Esp Enferm Digr 1990;78(suppl 1):83. splenism.29 As immune abnormalities are 17 Crabtree JE, Mahony MJ, Taylor JD, Heatley RV, Little- known to with a free diet and wood JM, Tompkins DS. Immune responses to Heli- improve gluten cobacter pylori in children with recurrent abdominal improvement in splenic function can fol- pain.J Clin Pathol 1991;4:768-71. 600 Crabtree, O'Mahony, Wyatt, Heatley, Vestey, Howdle, Rathbone, Losowsky

18 Crabtree JE, Shallcross TM, Wyatt JI, et al. Mucosal 25 Dixon MF, Wyatt JI, Burke DA, Rathbone BJ. Lymphocytic humoral immune response to Helicobacter pylori in gastritis-relationship to Campylobacter infection. patients with . Dig Dis Sci 1991;36:1266-73. Pathol 1988;154:125-32. 19 Kosunen TU, Hook J, Rauatelin HI, Myllyla G. Age- 26 Howdle PD, Losowsky MS. Coeliac disease. In: Losowsky dependent increase ofCampylobacter pylori antibodies in MS, Heatley RV, eds. Gut defences in clinical practice. blood donors. Scand Gastroenterol 1989;24:110-14. Edinburgh: Churchill Livingstone, 1986;243-54. 20 Sobala GM, Crabtree JE, Dixon MF, et al. Acute Heli- 27 Loft DE, Marsh MN, Sandle GI, et al. Studies of intestinal J Clin Pathol: first published as 10.1136/jcp.45.7.597 on 1 July 1992. Downloaded from cobacter pylori infection: clinical features, local and lymphoid tissue. XII. Epithelial lymphocyte and mucosal systemic immune response, gastric mucosal histology and responses to rectal gluten challenge in celiac sprue. gastric juice ascorbic acid concentrations. Gut Gastroenterology 1989;97:29-37. 199 1;32:1415-18. 28 Kastrup W, Andersson H, Gillberg R, Mobacken H, 21 Valnes K, Brandtzaeg P, Elgjo K, Stave R, Bekelin K, Fausa Stockbrugger R. Influence of gluten-free diet on the 0. Local immunoglobulin production is different in gastric condition in dermatitis herpetiformis. Scand gastritis associated with dermatitis herpetiformis and Gastroenterol 1985;20:39-45. simple gastritis. Gut 1987;28:1589-94. 29 Howdle PD, Losowsky MS. The immunology of coeliac 22 O'Mahony S, Vestey JP, Ferguson A. Similarities in intesti- disease. Bailliere's Clin Gastroenterol 1987;1:507-29. nal humoral immunity in dermatitis herpetiformis with- 30 Corazza GR, Frisoni M, Vaira D, Gasbarrini G. Effect of out enteropathy and in coeliac disease. Lancet gluten-free diet on splenic hypofunction in adult coeliac 1990;335: 1487-90. disease. Gut 1983;24:228-30. 23 Crabtree JE, Heatley RV, Losowsky MS. Immunoglobulin 31 Marshall B, Armstrong J, McGechie D, Glancy R. Attempt secretion by isolated intestinal lymphocytes: spontaneous to fulfill Koch's postulates for pyloric Campylobacter. production andT-cell regulation in normal Med _Aust 1985;142:436-9. and in patients with coeliac disease. Gut 1989; 30:347-54. 24 O'Mahony S, Arranz E, Barton JR, Ferguson A. Dissocia- tion between systemic and mucosal humoral responses in coeliac disease. Gut 1991;32:29-35. http://jcp.bmj.com/ on September 27, 2021 by guest. Protected copyright.