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1 Update on Celiac Disease Douglas L. Seidner, MD, AGAF, FACG Director, Center for Human Nutrition Vanderbilt University As revised/retold by Edward Saltzman, MD Tufts University

2 None Disclosures

3 This ppt Slides and Resources PDF of papers cited on slides Society statements and guidelines Gluten free foods and medications

4 Gluten Gluten = gliadin + glutenin Found in Wheat Similar proteins in Barley Rye Oats Wheat gluten corn gluten

5 Celiac Disease Immune mediated response to dietary gluten Inflammatory injury to small intestine mucosa Associated with a range of GI and extra GI symptoms Diagnosis by Antibody testing Genetic testing Small intestine biopsy

6 Fasano Scientific American 301, (2009)

7 Kagnoff J. Clin. Invest. 117:41 49 (2007)

8 Epidemiology ogy Prevalence ~1% 85% undiagnosed Associated with HLA DQ2 and DQ8 35% in general population Absence excludes celiac disease Kagnoff J. Clin. Invest. 117:41 49 (2007)

9 Hopper BMJ 2007;335:558-62

10 Typical Symptoms Adults and older children (majority of diagnoses) Diarrhea Bloating Flatulence Abdominal discomfort Weight loss Infants and young children Diarrhea or constipation Delayed growth Abdominal distention Vomiting

11 Atypical Symptoms Hematologic Bruising i Anemia Hyposplenism p Endocrine Short stature Delayed puberty Osteoporosis Osteomalacia Gynecologic Amenorrhea Infertility Gastroenterologic Constipation o Liver enzyme abn Neurologic Cerebellar ataxia Peripheral neuropathy Posterior / lateral column abn Neuromyopathies Psychiatric Depression Psychosis Schizophrenia

12 Top Diagnoses Before Diagnosis of Celiac Disease Average adult has had symptoms for 5 10 years prior to diagnosis is made* Anemia Allergies IBS Amoeba, parasites, Psychological infection Diarrhea Gallbladder disease IBD Thyroid disease Diabetes Cancer, lymphoma Ulcers Cystic fibrosis Viral illness Lactose intolerance Chronic fatigue GERD syndrome Wihtl Weight loss Green PHR et al. GE 2001;96:126

13 Cli Celiac Disease in Irritable Bowel lpti Patientst Ford Arch Intern Med. 2009;169(7):

14

15 Dilemmas Population screening Case finding Lower threshold for Antibody or genetic testing Small intestine biopsy

16 Dietary Management Gluten free diet for life Wheat, rye, barley Oats?

17 FDA 2007 What Is Gluten Free? < mg gluten/day protective against adverse clinical effects in most sensitive Translates to 1 ppm in food Limit of detection is 20 ppm Food can be labeled as gluten free if does not contain ti Wheat, rye, barley or crossbreeds 20 ppm gluten

18 Ot Oats in Cli Celiac Disease 5 yr FU of 6 12 mo RCT GFD vs. GFD + oats ad lib 23 + oats / 28 controls No difference in histopathology or serology Janatuinen EK et al. Gut 2002;50:332.

19 Ot Oats in Cli Celiac Disease The need to eliminate oats in controversial Some studies indicate that small amounts of oats may be safe Difficult to get uncontaminated oats Major organizations continue to recommend avoidance of oats

20 Micronutrients Iron Folate Calcium, vitamin D, bone With diarrhea or weight loss Vitamins B 12, A, E, D Zinc

21 Gluten Free Grains Amaranth Flax Nut flours Sorghum Arrowroot Job's tears Potato Soy Buckwheat Kasha Quinoa Tapioca Cassava Millet Ragi Teff Corn Montina Rice

22 Hidden Sources of Gluten Dairy Fats & oils Cheeses, reduced fat, flavored products Emulsifiers, flavorings Beverages Fruits Flavors, malt, mixers Dried fruits, pie filling, Snacks salads Flavoring Vegetables Condiments Mixes, cream sauce, Imitation ti spices / deep fried extracts, powdered Soups spices Bouillon & thickeners

23 Value of Adherence Adherence to gluten free associated with improvements in: Overall mortality Development of small intestine malignancy Bone mineral density Stature and body composition Iron dfii deficiency anemia Corrao G, et al. Lancet 2001 AGA Technical Review 2006

24 Gluten Sensitivity in Irritable Bowel Patients Without Celiac Disease gluten free diet ±2 slices wheat bread + 1 muffin Biesiekierski et al. Am J Gastroenterol11 January 2011; doi: /ajg

25 Biesiekierski et al. Am J Gastroenterol11 January 2011; doi: /ajg

26 Proposed Classification of Gluten Related Disorders Sapone et al. BMC Medicine 2012;10:13

27 Emerging Therapies n Crespo Pérez et al. Eur J Int Medicine 2012; 23:9 14

28 Conclusions Most cases of celiac disease are undiagnosed The spectrums of celiac disease and gluten sensitivity are emerging Gluten free diets should be followed in susceptible individuals and resources are available Emerging dietary and non dietary therapies

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