A.M. Report 5/5/09 Jason Haag, M.D.. Celiac Disease What is it? Small bowel disorder characterized...
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Transcript of A.M. Report 5/5/09 Jason Haag, M.D.. Celiac Disease What is it? Small bowel disorder characterized...
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Celiac Disease
A.M. Report5/5/09
Jason Haag, M.D.
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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
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Associated Condition’sDermatitis herpetiformis
Down’s SyndromeIgA DeficiencyDM type IThyroid diseaseAutoimmune hepatitis
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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)
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Whom to test?High Risk Pt
DM type I, autoimmune d/o, 1st/2nd degree related w/ Celiac dx
Asymptomatic individualsNo benefit to screening
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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
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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
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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
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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
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PreventionOsteoporosis
DEXA scan
HyposplenismPneumovax
Vitamin DefIron, folate, calcium vitamin D, B12
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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
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Take Home PointsTest with IgA anti tissue transglutaminase,
IgA endomysial antibody
Association with Dermatitis herpetiformis and IgA deficiency
Always test on gluten laden diet
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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