VIOLETA GABOVICH, MD

Inside of the Iceberg

RABIN MEDICAL CENTER

Case Presentation

• 25 year - old - female

• Early satiety

• Postprandial fullness

• Epigastric burning

• Physical exam: BMI – 23

• Family history: brother - celiac

Labs

Hb 13.5 g/dl

Ferritin 30 ng/ml

CRP 0.3 mg/dl

IGA 90 mg/dl

Transglutaminase IgA 4 U/ml

Deamidated gliadin

peptide antibodies 14

Endomysial Ab Neg

Celiac screen N

Gastroscopy

Duodenal Biopsy ?

Duodenal Biopsy

Diagnoses

• Dyspepsia

• Duodenal villous atrophy

DDx: Villous Atrophy

Marisa DeGaetani ,Am J Gastroenterol 2013

Gastric Metaplasia, Crohn’s,

Intestinal Lymphoma

Collagenous, Tropical Sprue

SIBO, Giardia

Common Variable Immunodeficiency

Autoimmune Enteropathy

Medicaions

Seronegative Villous Atrophy : Work-up

HLA DQ2 and DQ8

Immunoglobulin A,M,G

Medications

Travel history

Anti enterocyte antibodies

Giardia - stool

HIV

SIBO

Celiac Disease : First-degree Relatives

• DQ2/8 positive

• Serologic markers + 25%

• Histopathological alteration 50%

• Dyspepsia – most prevalent

• Miss 6% mucosal atrophy

L. Vaquero. Eur J Gastroenterol Hepatol, 2014

Celiac Disease: Iceberg Model

Celiac Screen

A. Tosco ,Clinical and Experimental Immunology , 2012

TTG Staining

TTG Staining

• Below the age of 2 years

• IgA deficiency

• Marsh – No correlation

• Specificity ?

• IBD ?

• Gluten free diet ?

• Marker – atrophy / inflammation

Saeeda Almarzooqi ,Pathology Research International , 2013

Treatment

• Gluten free diet

• Corticosteroids

• Immunosuppressive Rx

Am J Gastroenterol 2013

Dx: Seronegative Celiac

• HLA DQ2 +

• Gluten free diet

• Duodenal biopsy follow up

Celiac Serology

• IgA EMA (endomysial antibody)

• IgA tTG assays (tissue transglutaminase)

• AGA (antigliadin antibodies)

• DGP (deamidated gliadin peptides)