Celiac disease: No cake for you!

Presentation by Margaret Roberts

First described in 1880Link to diet was not described until 1950

In 1954, Dr. Paulley showed that intestinal mucosa was damaged

History of celiac disease

Walker and Murray 2010

Autoimmune Disease Response to barley, wheat, and rye It can affect the gut, skin, joints, uterus,

brain, heart, and other organs 1 in 100 have celiac disease

Celiac Disease

Walker and Murray 2010

Requires a joint clinicopathological approach

First-line test is serology with immunoglobulin A (IgA) tissue transglutaminase and IgA endomysial antibodies.

Second, biopsy is the best to confirm the diagnosis of celiac disease

Diagnosis

Walker and Murray 2010

While the sensitivity of IgA to detect celiac disease is 91%, this test has a positive predictive value of only 29%◦ In one study up to one in 13 cases of celiac disease

were undetected by serology IgA deficiency is the most common primary

immune deficiency, affecting one in 400 to one in 600 of the general population, and a high proportion of those tested for celiac disease

Serology

Walker and Murray 2010

Biopsy should occur in the duodenum, preferably the second portion of it.

Duodenal bulb is a secondary location Suggested that biopsies should occur four to five times

before true diagnosis can be made

Biopsy

Classical scalloping of duodenal mucosa seen in established celiac disease at endoscopy.

Walker and Murray 2010

Normal versus Celiac small bowel biopsy.

Top: Normal small bowel biopsy with finger-like villi.

Bottom: Celiac small bowel biopsy with villous atrophy and hypertrophy of crypt.

Martin 2008

Nausea, Diarrhea, vomiting Irritability, fatigue Itchy rash over arms, elbow, scalp, face and

knees Lactose intolerance, infertility, depression,

and elevated liver enzymes

Symptoms of CD

Martin 2008

Have a three-fold higher risk of non-Hodgkin Lymphoma as well as cancer of the gastrointestinal tract. Lower risk of postmenopausal breast cancer because of lower obesity rates.

Iron deficiency anemia is also prevalent due to malabsorption

Worse cases have megablastic anemia because of B12 deficiency

Side effects of CD

Martin 2008

Introduction to complementary foods too soon

Introduction to complementary foods too late

Use of formula instead of breast milk Genes OR … A combination of the four?

Possible Causes:

Early in life, the body is building up immune functions as well as proper responses to food

Without the proper enzymes to digest a food, the body treats it like an antigen/allergen

Allergen exposure too early when the gut colonization and local immune networks are less established may increase the risk of allergic or autoimmune disease

Introduction of Complementary foods too soon

Prescott, Smith, Tang, Palmer, Sinn, Huntley, Cormac et. al 2008

Evidence that waiting until after six months to introduce complementary foods increases food allergies

Instead, there is a critical period during which complementary foods must be introduced

Animal studies suggest this age to be 4-6 months

Introduction of complementary foods too late

School of Pediatrics and Child Health Research 2008

Studies show that breast feeding at least delays the onset of celiac disease

Continued breastfeeding promotes tolerance and have protective effects during the time when complementary feeding is initiated.

Use of breast milk vs. formula

Breast milk may limit amount of gluten absorbed

Prevention of gastrointestinal infections by breast milk

Human milk IgA antibodies may diminish immune response to ingested gluten

The immune modulating property of human milk may be exerted through its T-cell specific suppressive effect.

Celiac disease and breast milk

Selimoglu, Mukadder Ayse MD; Karabiber, Hamza MD 2010

VERY strong correlation Virtually all patients carry human leukocyte

antigen (HLA)-DQ2 or HLA-DQ8 The absence of these molecules has a

negative predictive value for celiac disease close to 100%.

Genes

Walker and Murray 2010

The best treatment is a gluten-free diet. This has a near 100% chance of relieving most, if not all symptoms

Unfortunately, sticking to the diet is very hard

Also, gluten-free diet is correlated with anger, sadness, and despair

Treatment

Selimoglu, Mukadder Ayse MD; Karabiber, Hamza MD 2010

Enzyme supplement treatment◦ Lack of endoprolyl peptidase (PEP)◦ Administration of enzymes with meals can

complement gastric and pancreatic enzymes in detoxification of ingested gluten

Designer carbohydrates◦ The aim is the production of wheat that is devoid

of biologically active peptide sequences Correction of impaired Intestinal

permeability

Newest treatments

Selimoglu, Mukadder Ayse MD; Karabiber, Hamza MD 2010

Martin, S. (May 2008). Against the grain: an overview of celiac disease. Journal of the American Academy of Nurse Practitioners. 20(5),243-50

Selimoglu, Mukadder Ayse MD; Karabiber, Hamza MD (January 2010). Celiac disease: prevention and treatment. Journal of Clinical Gastroenterology. 44(1), 4-8.

School of Pediatrics and Child Health Research. (2008 August). The importance of early complementary feeding in the development of oral tolerance: concerns and controversies. Pediatric Allergy and Immunology. 19(5), 375-80

Walker, M. Murray, J. (3 November 2010). An update in the diagnosis of coeliac disease. Histopathology. Obtained from PubMed.gov.

Works Cited