Effect of Elemental Diet on Mucosal Immunopathology and Clinical Symptoms in Type 1 Refractory Celiac Disease  Richard Willfred Olaussen, Astrid Løvik, Stig Tollefsen, Per Arne Andresen, Morten H. Vatn, Thomas De Lange, Jorunn Bratlie, Per Brandtzaeg, Inger Nina Farstad, Knut E.A. Lundin  Clinical Gastroenterology and Hepatology  Volume 3, Issue 9, Pages 875-885 (September 2005) DOI: 10.1016/S1542-3565(05)00295-8 Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 1 Histopathologic changes in mucosal lesions after elemental diet (H&E staining). Micrographs of type 1 RCD patients (A, B) 5, (C, D) 7, and (E, F) 9, (A, C, E) before and (B, D, F) after treatment, are shown. (A) Patient 5 had a flat mucosa with subepithelial collagenous bands before diet, (B) but developed some villi after treatment. Inserts show vacuolated epithelium heavily infiltrated with leukocytes and almost normalized epithelium (arrows), respectively. Patient 7 had a collagenous subepithelial band with detached epithelium (C, insert, *) before but not (D) after treatment; capillaries now have replaced the band (short arrow) and the epithelium is attached to the basement membrane. In patient 9, increased numbers of IELs were seen (E, insert) before but not (F, insert) after treatment (arrows) (original magnification, 200×; A and B inserts, 400×; C and F, 630×). Clinical Gastroenterology and Hepatology 2005 3, 875-885DOI: (10.1016/S1542-3565(05)00295-8) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 2 IL-15 expression shown by immunohistochemical staining (red) (A, C) before and (B, D) after elemental diet. The epithelial (ep) and lamina propria (lp) expression pattern varied considerably among type 1 RCD patients. (A, B) Patient 5 showed (A) strong epithelial but (A, arrow) virtually no lamina propria staining before the diet compared with (B) reduced epithelial but (B, arrow) increased lamina propria staining after the diet. (C, D) By contrast, in patient 3 the epithelium was fairly negative both (C) before and (D) after the treatment but the lamina propria staining was reduced after the diet (original magnification, 250×). Clinical Gastroenterology and Hepatology 2005 3, 875-885DOI: (10.1016/S1542-3565(05)00295-8) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 3 Flow-cytometric analysis of duodenal cell suspensions obtained from type 1 RCD patient 5, showing the number of IFN-γ–secreting cells among (A–D) viable CD3+ and (E–F) CD8+ cells in the lymphocyte region of the (A, B, E, and F) epithelial and (C, D, G, and H) lamina propria samples (A, C, E, and G) before and (B, D, F, and H) after elemental diet. The cursor positions were set according to plots obtained with concentration- and isotype-matched antibodies. Clinical Gastroenterology and Hepatology 2005 3, 875-885DOI: (10.1016/S1542-3565(05)00295-8) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 4 Compiled flow-cytometric data for (A–C) duodenal epithelial and (D–F) lamina propria cell suspensions from type 1 RCD patients 2–7 indicated by different symbols. Plots connected by lines show individual proportions (%) of IFN-γ–secreting cells before and after elemental diet among viable cells in the (A, D) lymphocyte region and among (B, E) CD3+ or (C, F) CD8+ cells within this region. Note different scales of vertical axes. ♦, patient 2; ■, patient 3; ▴, patient 4; ×, patient 5; *, patient 6; •, patient 7. Clinical Gastroenterology and Hepatology 2005 3, 875-885DOI: (10.1016/S1542-3565(05)00295-8) Copyright © 2005 American Gastroenterological Association Terms and Conditions

Figure 5 Duodenal total mucosal IFN-γ mRNA levels quantified relative to GAPDH mRNA levels before (□) and after (■) elemental diet for each of 9 type 1 RCD patients (patients 2–10) determined on the basis of separate standard curves constructed for each gene by means of serial dilutions of control mRNA (relative scale, vertical axis). Clinical Gastroenterology and Hepatology 2005 3, 875-885DOI: (10.1016/S1542-3565(05)00295-8) Copyright © 2005 American Gastroenterological Association Terms and Conditions