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

Uptodate.com