Celiac Disease
A.M. Report5/5/09
Jason Haag, M.D.
Celiac DiseaseWhat is it?
Small bowel disorder characterized by Mucosal inflammation Villous atrophy Crypt hyperplasia
That occur with exposure to gluten and improve with its withdrawal
Associated Condition’sDermatitis herpetiformis
Down’s SyndromeIgA DeficiencyDM type IThyroid diseaseAutoimmune hepatitis
Whom to test?Chronic GI Sx
Diarrhea, malabsorption, weight loss, abdominal distention
Nutritional disordersElevated liver enzymes, delayed puberty, Fe-
def anemia, recurrent fetal loss, infertility, ? Osteoporosis (2/2 Vit D def)
Whom to test?High Risk Pt
DM type I, autoimmune d/o, 1st/2nd degree related w/ Celiac dx
Asymptomatic individualsNo benefit to screening
How to test?First – make sure Pt is on a gluten-containing
dietIf already on gluten free diet then test after 2-4
weeks of resuming gluten-containing diet
Low probabilitySerological testing
IgA anti tissue transglutaminase (sens 90%, spec 95%) IgA endomysial antibody (sens 90%, spec 97%) Antigliadin antibody no longer in routine use (sens 80%,
spec 85%) 2nd generation test in development
How to test?High probability
Serological testing as before
Small bowel biopsy Duodenal mucosa appears atrophic with loss of
folds, contian visible fissures, and may have nodular appearance
How to test?If patient has clinical features, but negative
serologyConsider IgA deficiency
Can test for IgG EMA or tTGPerform small bowel biopsyTest for HLA type
99% of patients with celiac have DQ2 and DQ8 types compared to 40% of general population
Consider other diagnosis
TreatmentGluten-free diet
High sources of gluten Wheat, rye, barley, oats
“Safe” foodsSoybeans, rice, corn, potatoes
Careful with lactose foodsMay worsen symptoms as many with celiac
disease have lactose intolerance
PreventionOsteoporosis
DEXA scan
HyposplenismPneumovax
Vitamin DefIron, folate, calcium vitamin D, B12
Monitoring ResponseCan follow serial IgA tTG
Check approx 6 months to 1 year after initiation of gluten free diet
Only works if antibody level elevated prior to therapy
Debate over repeat small bowel biopsyIf preformed usually at 3 months after gluten free
diet
If no improvement with glute-free diet can consider a gluten challenge and follow symptoms
Take Home PointsTest with IgA anti tissue transglutaminase,
IgA endomysial antibody
Association with Dermatitis herpetiformis and IgA deficiency
Always test on gluten laden diet
ReferencesRostom, A, et al. Celiac Disease. Summary,
evidence report. Agency for Healthcare Research and Quality, Rockville, MD 2004
Kelly, CP et al. Diagnosis and treatment of gluten-sensitive enteropathy. Adv Intern Med 1990; 35: 341.
Green, PH, Cellier, C. Celiac Disease. NEJM 2007; 357:1731
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