Challenges in Celiac Disease Adam Stein, MD Director of Nutrition Support Northwestern University Feinberg School of Medicine
Disclosures None
Overview Celiac disease Cases
Celiac disease Inappropriate immune reaction to gluten Genetic predisposition Small bowel enteropathy Wide variety of clinical symptoms ~1% prevalence
Gluten Protein (Latin- glue) Found in wheat, rye, barley Provides a flexible quality to baked goods
Celiac disease: diagnosis Duodenal biopsy Serologic markers Response to gluten-free diet HLA type
Celiac disease: serologic markers * These numbers are all over the place in the literature. REMEMBER: patients must have adequate ability to make IgA, IgG
Celiac disease: treatment Gluten free diet
Celiac disease: follow up Rubio-Tapla et al. Am J Gastroenterol 2013
Case #1: Initial diagnosis
Case #1 31yoF without any medical problems Bloating, constipation x 6 months Fatigue / brain fog Minimal improvement with various bowel regimens
When to suspect celiac disease 300+ associated symptoms Asymptomatic GI Really anything Non-GI Iron deficiency Dermatitis herpetiformis (DH) brain fog Bone thinning Family history Other autoimmune diseases Screen everyone??
Celiac disease: workup Rubio-Tapla et al. Am J Gastroenterol 2013
Controversy in kids (diagnosis) ESPGHAN No biopsy needed to confirm Celiac if: TTGA > 10x ULN EMA positive on two separate blood samples HLA predisposition Husby et al. J Pediatr Gastroenterol Nut 2012; 54:136-60
Celiac disease: workup Rubio-Tapla et al. Am J Gastroenterol 2013
Case #1 TTGA IgA: 87 u/ml (normal < 10 U/mL) (TTGA = Tissue Transglutaminase Antibody)
Celiac disease: workup Rubio-Tapla et al. Am J Gastroenterol 2013
Case #1
Case #1 Freeman. Can J Gastroenterol 2008; 22:273-280
Marsh classification IELs >25/100 enterocytes Shuppan et al. Dtsch Arztebl Int 2013; 110:835-45 www.massgeneral.org
Celiac disease: workup Rubio-Tapla et al. Am J Gastroenterol 2013
Not all that atrophies is celiac Medications (ARBs) Infection Viral Tropical sprue Giardia Whipple disease Bacterial overgrowth Malnutrition in general GVHD CVID Crohn s Peptic damage Eosinophillic gastroenteritis
Case #2: Diagnosis on a gluten gree diet
Case #2 38yoF without medical problems Gluten free diet Constipation/bloating
Celiac disease: workup (gluten-free) Rubio-Tapla et al. Am J Gastroenterol 2013
Case #2 TTGA IgA: 5 u/ml (normal < 10 U/mL)
Celiac disease: workup (gluten-free) Rubio-Tapla et al. Am J Gastroenterol 2013
Case #2 HLA DQ2/DQ7
Celiac disease: workup (gluten-free) Rubio-Tapla et al. Am J Gastroenterol 2013
Case #3: Problems on a Gluten Free Diet
Case #3 49yoM with celiac disease x 5 years Bloating, irregular bowel habits New iron deficiency anemia
Case #3 Rubio-Tapla et al. Am J Gastroenterol 2013
Case #3 TTGA IgA: 93 u/ml (normal < 10 U/mL) Dietitian appointment
Case #3 Rubio-Tapla et al. Am J Gastroenterol 2013
Celiac disease: follow up Rubio-Tapla et al. Am J Gastroenterol 2013
Case #3 Repeat labs 3 months later No longer iron deficient TTGA IgA now 7 u/ml
Case #3 Returns 6 months later Bloating/constipation worse Gained 10 lbs
Common problems after diagnosis Bloating/constipation Weight gain Periods of symptom relapse
Bloating/constipation Common problem on a gluten free diet Ensure no active inflammation Consider abdominal Xray Treat like IBS-C Bowel regimen (polyethylene glycol) Hydrate Adjust fiber intake Reassurance
Weight gain More common than weight loss
Gluten versus Gluten Free
Case #4: Ongoing inflammation
Case #4 44yoF with celiac disease x 1 year Strict gluten free diet Ongoing diarrhea Serologies + biopsy still abnormal
Case #4 Rubio-Tapla et al. Am J Gastroenterol 2013
Refractory celiac disease 12+ months of persistent/recurrent villous atrophy on a strict gluten free diet Prevalence 1-2% Type 1 Mucosal lymphocytes are identical (clonal) to Celiac disease Treatment- steroids/azathioprine,?mesalamine, symptom control, nutritional interventions Type 2 Mucosal lymphocytes are abnormal (premalignant T-cell lymphoma) CD3 T-cells lack CD8 expression Oligoclonal T-cell expansion (lack of diversity) Same therapy, less likely to work, usually need TPN Poor prognosis Rubio-Tapla et al. Am J Gastroenterol 2013
Celiac disease: take-home points Find a good dietitian Secure the diagnosis Follow an algorithm for follow up Find the gluten Watch for weight gain and IBS-C Refractory celiac is rare
Questions??