Membrane leaking permits peptides of gliadin that stimulate two levels of the immune response: the innate response, and the adaptive (T-helper cell-mediated) response. One protease-resistant peptide from α-gliadin contains a region that stimulates lymphocytes and results in the release of interleukin-15. This innate response to gliadin results in immune-system signalling that attracts inflammatory cells and increases the release of inflammatory chemicals. The strongest and most common adaptive response to gliadin is directed toward an α2-gliadin fragment of 33 amino acids in length.The response to the 33mer occurs in most coeliacs who have a DQ2 isoform. This peptide, when altered by intestinal transglutaminase, has a high density of overlapping T-cell epitopes. This increases the likelihood that the DQ2 isoform will bind, and stay bound to, peptide when recognised by T-cells. Gliadin in wheat is the best-understood member of this family, but other prolamins exist, and hordein (from barley), secalin (from rye), and avenin (from oats) may contribute to coeliac disease. Avenins toxicity in people with coeliac disease depends on the oat cultivar consumed, as prolamin genes, protein amino acid sequences, and the immunoreactivities of toxic prolamins vary among oat varieties. Tissue transglutaminase
Anti-transglutaminase antibodies to the enzyme tissue transglutaminase (tTG) are found in the blood of the majority of people with classic symptoms and complete villous atrophy, but only in 70% of the cases with partial villous atrophy and 30% of the cases with minor mucosal lesions. Tissue transglutaminase modifies gluten peptides into a form that may stimulate the immune system more effectively.
Salpingitis isthmica nodosa (SIN), also known as diverticulosis of the Fallopian tube, is nodular thickening of the narrow part of the  uterine tube, due to inflammation. Signs and symptoms
SIN is associated with infertility and ectopic pregnancy, and may present as either. Pathology
It is characterized by nodular thickening of the tunica muscularis of the narrow (isthmic) portion of the Fallopian tube. In severe cases, it leads to complete obliteration of the tubal lumen. It is uncommonly bilateral.Gross Findings:

One or more nodules 1–2 mm, spanning up to 2 cm
Smooth serosaMicroscopic Findings:

Glandular epithelium within tubal muscularis propria, in continuation with mucosa or (more commonly) discontinuous
Haphazard distribution (akin to adenomyosis) or pseudoinfiltrative
Banal epithelium with tubal differentiation

Diagnosis
Hysterosalpingography, a common technique in the work-up of infertility, is reliable in the diagnosis of SIN, which is seen as small globular collections within the tubal wall, either discontinuous or in continuity with the tubal lumen. Tubal obstruction and hydrosalpinx are commonly seen as well. Other techniques include laparoscopic chromopertubation, salpingoscopy, and transvaginal hydrolaparoscopy (the latter allows visualization of the tubal mucosa)

Treatment
Once suspected clinically and radiologically, patients with infertility and SIN can be managed with segmental resection with tubo-cornual anastomosis, and recanalization if tubal obstruction is detected. Success with gonadotrophin-releasing hormone analogues (GnRH-a) has been documented in terms of remission of nodularity and tubal patency. If fertility preservation is not desired, salpingectomy is recommended. See also
Vasitis nodosa
Salpingitis


== References ==