Gluten Sensitivity Fact from Myth Justine Turner MD PhD University of Alberta Disclosures None Relevant OBJECTIVES Understand the spectrum of gluten disorders Develop a diagnostic algorithm for gluten disorders Understand the risks and benefits of being gluten free 1
This is Celiac Disease in 2013? This is Celiac Disease in 2013? Celiac Disease in 2013 2
Celiac Disease Autoimmune enteropathy Triggered by gluten (wheat, rye, barley) HLA genes necessary but not sufficient 30% population HLA DQ2/8 1% population have celiac disease Edmonton Pediatric Celiac Clinic Diagnoses 1998-2012 Chronic or recurrent diarrhea Abdominal distension FTT or weight loss Abdominal pain Vomiting Constipation IBS Fatigue Celiac Disease Presentations Short stature Irritability, inattention Iron deficiency anemia resistant to Rx Hepatitis Arthritis Headaches Epilepsy Dermatitis herpetiformis 3
First degree relatives Type 1 diabetes Autoimmune Thyroiditis Down Syndrome Turners Syndrome Williams Syndrome Selective IgA deficiency Celiac Disease No Symptoms COMMON 6X Prevalence Symptomatic Celiac Disease Wheat Allergy is triggered by exercise? Wheat Allergy is triggered by exercise? 4
Wheat Allergy Food allergy is immune mediated Wheat is a common food allergen milk, soy, egg, corn, peanuts more common More commonly considered than present non-ige symptoms (abdominal pain, rashes...) Bakers Asthma Exercise induced anaphylaxis Allergy test (only) when clinical suspicion Gluten Sensitivity is bad for my belly and my brain Gluten Sensitivity is bad for my belly and my brain 5
Gluten Sensitivity Gluten reaction that is not allergy or autoimmune Symptoms overlap commonly GI & CNS Emerging evidence is immune mediated Can have Marsh I histology Emerging biomarkers (AGA+) Rule our Celiac and IgE allergy Responds to GFD (Double Blind) A Gluten free world is a good thing? A Gluten free world is a good thing? 6
Gluten Free World Here A Gluten free world is a good thing? The GFD Is expensive Is onerous Can lack nutrients fiber, iron, folate... gluten free foods are not fortified Can increase weight gain high fat, sugar, calorie content Only essential life-long for Celiac Disease Gluten and IBS (A) Diet effect on stool frequency (P =.04), form, and ease of passage; the effect on stool frequency was greater in HLA-DQ2 or HLA-DQ8 positive patients (P =.019) (B) Mean bowel movements per day during 14-day baseline and 28-day diet treatment periods in each patient randomized to gluten-free and gluten-containing diets. HLA-DQ2/8 negative patients are indicated by the open symbols 7
Gluten and IBS (A) Diet effect on stool frequency (P =.04), form, and ease of passage; the effect on stool frequency was greater in HLA-DQ2 or HLA-DQ8 positive patients (P =.019) (B) Mean bowel movements per day during 14-day baseline and 28-day diet treatment periods in each patient randomized to gluten-free and gluten-containing diets. HLA-DQ2/8 negative patients are indicated by the open symbols TAKE HOME MESSAGES Celiac disease is common and must be considered for a range of symptoms Gluten allergy and gluten sensitivity exist, but are not celiac disease Gluten intolerance is common, but exclude a true gluten disorder first Gluten free is common, but not easy TAKE HOME MESSAGES Celiac disease is diagnosed by your index of suspicion; attg; biopsy (in Canada) Gluten allergy is diagnosed by IgE tests Gluten sensitivity is diagnosed by double blind food challenge (in 2013) Help your patients understand the advantages and disadvantages of GFD 8
Time exposure to symptoms Pathogenesis Celiac Disease Wheat Allergy Gluten Sensitivity Weeks - years Minutes - hours Hours - days Autoimmune (innate and adaptive) IgE non-ige HLA genetics 97% 30-40% (general population)?immune?innate 50% attg / EMA Usually positive Absent Absent Enteropathy Usual Absent?Slight increase IELs Symptoms Complications Indistinguishable Intestinal and extra-intestinal long-term short-term?none without GFD Adapted from Fasano et al; NEJM 2012; v367; p2419-26 9