Meredythe A. McNally, M.D. Gastroenterology Associates of Cleveland Beachwood, OH

Meredythe A. McNally, M.D. Gastroenterology Associates of Cleveland Beachwood, OH

Case in point 42 year old woman with bloating, gas, intermittent diarrhea alternating with constipation, told she has IBS for years vs. 42 year old woman with lifelong inability to gain weight, bloating, worsening explosive diarrhea, thin bones, thyroid problem. Which patient has Celiac disease?...it s complicated

What is Celiac Disease? Also known as: Gluten Sensitive Enteropathy Celiac Sprue Non-Tropical Sprue First Described 1888 ( Maybe 2 nd century) Autoimmune disorder of the intestine Genetically predisposed individuals exposed to gluten Lifelong disorder affecting children & adults Issue of Malabsorption Why don t we absorb our nutrients in celiac disease?

What is Celiac Disease? Malabsorption ( Bad Absorption ) Process that interrupts or impairs absorption Gluten Occurs in wheat & related grains barley, rye Lesser occurance in Oats Reaction occurs when small bowel lining is exposed to gluten damages lining Villi ( fingers ) become flat MALABSORPTION

Normal Villi of Small Intestine

Villi in Celiac Disease

Who is at risk for Celiac Disease? Prevalence is 1 in 133 1 in 300 Increases with age May have had symptoms for 10 years Caucasians of Northern European Background Anyone can develop it if genetics are right (HLA DQ2, HLA DQ8) Relatives with Celiac Other Autoimmune issues Certain Genetic Syndromes Down Syndrome, Turner Syndrome, Prader-Willi Syndrome

What are the symptoms of Celiac Disease? Abdominal Pain Bloating Flatus Diarrhea (Fatty or Oily) Weight Loss Skin Rash Failure to Thrive or Slow Growth Some of these are very vague & common symptoms

Diverse Symptom List

What are other problems associated with Celiac Disease? Osteoporosis, Low Vitamin D levels Anemia Liver Enzyme Abnormalities Low Iron Levels Depression Peripheral Neuropathy, Headache Hyposplenism (at risk for certain infection type) Kidney Disease Arthritis Rash (Dermatitis Herpetiformis) Infertility Other Autoimmune Disorders (Diabetes, Thyroid Problems, Microscopic Colitis)

Who do I ask about it? Ask your primary care provider Ask a Gastroenterologist ( GI Doc ) Specialist in the Digestive System The 25-foot-long tube processes food & nutrients Liver, Pancreas & Gallbladder Break down & absorb food Nutrients can then be transported into the blood stream & delivered to cells throughout the body You may require specialized testing Endoscopy Genetic Testing

Gastrointestinal Tract

How do you diagnose Celiac Disease? High Index of Suspicion Blood Tests All testing must be done on a gluten-containing diet!! Serum Antibody Assays IgA Endomysial Ab: Sensitivity 85-98%, Specificity 97-100% IgA Tissue Transglutaminase Ab: Sensitivity 93%, Specificity 99% IgA Antigliadin Ab: Sensitivity 75-90%, Specificity 82-95% IgG Antigliadin Ab: Sensitivity 69-85%, Specificity 73-90% Antigliadin Ab not recommended for screening or diagnosis except in IgA deficiency HLA DQ2/DQ8 genetic testing (genes that regulate immune response) Endoscopic Biopsies: GOLD STANDARD

Tests after a Celiac Diagnosis Blood work Nutritional Deficiencies Iron, Folic acid, B12, Calcium, Vit D, Vit K Liver Enzyme Abnormalities Thyroid levels Tests for bone loss (osteoporosis) DEXA Skin Exam Eye Exam Vaccinations

Classification of Celiac Disease Classical Celiac Antibody positive, histological findings & classic symptoms Atypical Celiac Antibody positive, histological findings, milder clinical symptoms Most common type Silent Celiac Antibody positive, histological findings, asymptomatic Potential Celiac Antibody positive, negative biopsies, asymptomatic Latent Celiac Previous diagnosis that responded to gluten-withdrawal but retained normal villous architecture after gluten re-challenge

Clinical Manifestations Classic Celiac Diarrhea, Steatorrhea, Flatulence Symptoms of malabsorption Short Stature Severe Anemia (microcytic or macrocytic) Osteopenia Subclinical Disease 50% of patients do not have diarrhea Borderline Fe Deficiency Fatigue No symptoms at all

Normal vs. Celiac Disease

Celiac Disease Pathology Intraepithelial lymphocytes Villous atrophy Crypt Hyperplasia Increased lymphocytes macrophages, plasma cells and eosinophils This slide courtesy of Dr. Meredythe McNally Mayo Clinic April 2, 2011 Malabsorption/Celiac - OAPA Conference 18

Endoscopic View of Celiac

How do you treat Celiac Disease? Gluten Free Diet Foods containing wheat, rye, and barley should be avoided Soybean or tapioca flours, rice, corn, buckwheat, potatoes are safe Fruits & Vegetables are safe Read labels on prepared foods and condiments carefully Pay attention to additives (stabilizers, emulsifiers) that may contain gluten Dairy products may not be well tolerated initially since many patients with celiac disease also have lactose intolerance Oats do not appear to be harmful Oats should be avoided unless package specifically states that product is gluten free & was processed in gluten free facility May take months for villi to heal Recommend a nutritionist specializing in Celiac Disease

Potential Sources of Contamination Commercial cereals Eating out Communion wafers Lipstick Airborne flour/ starch Soy sauces made with wheat Mislabeled or unlisted ingredients Medication

Ingredients to Question (may contain gluten) A. Seasonings and spice blends or mixes B. Modified food starch C. Malt/ malt extract/ flavoring D. Modified hop extract and yeast-malt sprout extract E. Dextrin F. Caramel color

Dietary Adherence A Common Problem! Only 50% of Americans with chronic illness adhere to their treatment regimen including Diet Exercise Medication Dietary compliance can be the most difficult aspect of treatment

Barriers to Compliance Time pressure Time to plan, prepare food is longer Planning Work required to plan meals Competing priorities Family, job, etc. Assessing gluten content in foods/label reading Eating out Avoidance, fear, difficult to ensure food is safe

Why should we treat Celiac Disease? High Risk for Ulcerative Jejunitis T-Cell Lymphoma of Small Intestine Adenocarcinoma of Small Intestine Higher Mortality Rate Development of other potential long term health problems

Useful Celiac Websites National Digestive Disease Information Clearinghouse http://digestive.niddk.nih.gov Celiac Sprue Association http://www.csaceliacs.org Gluten Free Restaurants in Cleveland and Guides to Gluten Free Living http://glutenfreeincleveland.blogspot.com http://www.specialgourmets.com/resource http://celiachandbook.com Greater Cleveland Celiac Association http://clevelandceliac.webs.com