dewqpk 2010-1-22 11:42
乳糜瀉增加神經與精神異常風險
作者：Allison Gandey
出處：WebMD醫學新聞
January 7, 2010 — 一篇新研究顯示，乳糜瀉病患常會有偏頭痛與腕隧道症候群（Carpal tunnel syndrome）。
篩檢經切片證實乳糜瀉的72名病患之後，研究者報告指出，許多人有精神方面問題，35%的乳糜瀉病患有憂鬱、人格改變或精神病病史。
研究作者指出，6%至10%的乳糜瀉病患有非典型的神經表現。之前的研究認為，小腦性共濟失調是最常見的症狀，這篇新研究觀察發現，6%的病患有小腦性共濟失調，其他6%有前庭功能不良，整體而言，26%的病患經歷過輸入性共濟失調。
約三分之一的病患有站立與步態問題，許多人經歷深度感覺喪失與減少腳踝反射。
德國Marburg大學的Katrin Burk醫師等研究者報告指出，乳糜瀉的步態問題不只是因為小腦性共濟失調，也可能因為本體感受或前庭缺損，即使嚴格遵守無麩質飲食，仍然有可能發生神經問題。
該研究發表於12月15日的Movement Disorders期刊。
【觀察偏見】
這72名乳糜瀉病患是透過廣告與使用一個標準問卷訪談後納入。
研究者指出，這領域中的研究多數聚焦在一線神經照護的病患，為了排除此類觀察偏見，對經切片證實為乳糜瀉的病患篩檢神經疾病。
約有三分之一(28%)乳糜瀉病患報告有偏頭痛病史，在許多案例中，導入無麩質飲食之後，偏頭痛發作頻率與強度都降低。
約有20%的病患經歷腕隧道症候群，研究者報告指出，令人驚訝的是，癲癇比預期的少，只有4個人出現大發作或局部發作。
動作問題如基底核症狀、椎狀體路徑症狀、抽動與肌躍症較不常見，總共有14%的病患報告有膀胱功能不佳。
【可能有多種機轉】
乳糜瀉中，造成神經疾病的機轉還不甚瞭解，缺乏葉酸、維他命E與生物喋呤(Biopterin )都對病理原因有所影響；不過，研究者報告指出，多數案例中，替代治療無法緩解臨床症狀。
研究者指出，維他命缺少症很少引起乳糜瀉患者的明顯異常，多數的神經症狀並沒有任何營養缺乏的證據。
他們指出，乳糜瀉的神經表現是引人注意的，必須認為不是偶發的，病患的無麩質飲食會緩解腸道症狀，但是無法預防發生神經缺損。
研究者認為，因為考量臨床差異，有許多不同的病理機轉可能會造成乳糜瀉的神經和精神功能不佳。
研究者皆宣告沒有相關財務關係。
Mov Disord. 2009;24:2358-2362.
Celiac Disease Increases Risk of Neurological and Psychiatric Disorders
By Allison Gandey
Medscape Medical News
January 7, 2010 — Migraine and carpal tunnel syndrome are common among celiac patients, a new study shows.
After screening a cohort of 72 patients with biopsy-proven celiac disease, researchers also report that many experience psychiatric problems, with 35% of celiac patients reporting a history of depression, personality changes, or psychosis.
Atypical neurological presentations are thought to occur in 6% to 10% of celiac patients, the study authors note. Prior studies have suggested that cerebellar ataxia is the most frequent symptom. This new study observed cerebellar ataxia in 6% of patients. Another 6% had vestibular dysfunction. In all, 26% of patients experienced afferent ataxia.
About a third of patients had stance and gait problems, and many experienced deep sensory loss and reduced ankle reflexes.
"Gait disturbances in celiac disease do not only result from cerebellar ataxia but also from proprioceptive or vestibular impairment," report investigators led by Katrin Burk, MD, from the University of Marburg in Germany. "Neurological problems may develop despite strict adherence to a gluten-free diet."
Neurological problems may develop despite strict adherence to a gluten-free diet.
The study is published in the December 15 issue of Movement Disorders.
The 72 patients with celiac disease were recruited through advertisements and interviewed using a standard questionnaire.
"Most studies in this field are focused on patients under primary neurological care," the researchers note. "To exclude such an observation bias, patients with biopsy-proven celiac disease were screened for neurological disease."
About a third of celiac patients (28%) reported a history of migraine. In many cases, there was a decrease in the frequency and intensity of migraine attacks after the introduction of a gluten-free diet.
About 20% of patients experienced carpal tunnel syndrome. "Surprisingly, epilepsy was less common than expected," report the researchers. "Only 4 individuals presented with a history of generalized or focal seizures."
Motor problems, such as basal ganglia symptoms, pyramidal tract signs, tics, and myoclonus, were infrequent. A total of 14% of patients reported bladder dysfunction.
Multiple Mechanisms Likely
In celiac disease, the mechanisms leading to neurological disease are not yet understood. Deficiencies in folic acid, vitamin E, and biopterin have been implicated in the pathogenesis; however, the investigators report that replacement therapy does not resolve clinical symptoms in most cases.
The researchers point out that hypovitaminosis rarely causes overt abnormalities in celiac patients, and most with neurological symptoms do not show evidence of any nutritional deficiencies.
"The prevalence of neurological manifestations in celiac disease is striking and must be considered more than accidental," they note. "The patients' gluten-free diet had resolved intestinal symptoms but had not prevented the development of neurological deficits."
The investigators suggest that because of the considerable clinical variability, many different pathogenic mechanisms are likely to contribute to the neurological and psychiatric dysfunction in celiac disease.
The researchers have disclosed no relevant financial relationships.
Mov Disord. 2009;24:2358-2362.