CELIAC DISEASE Ruben Gonzalez-Vallina, MD. Director Gastroenterology OutPatient Initiatives Miami Childen’s Hospital

Relevant Disclosures Commercial Interest – None There is no financial relationships relevant to the content of presentation.

Definition Celiac disease is an immune-mediated enteropathy caused by a permanent sensitivity to gluten in genetically susceptible individuals. It occurs in symptomatic subjects with gastrointestinal and non-gastrointestinal symptoms, and in some asymptomatic individuals, including subjects affected by: - Type 1 diabetes - Williams syndrome - Down syndrome - Selective IgA deficiency Turner syndrome - First degree relatives of individuals with celiac disease

Genetic Disorders Down Syndrome: 4-19% Turner Syndrome: 4-8% Williams Syndrome: 8.2% IgA Deficiency: 7% Can complicate serologic screening

Relatives Healthy population: 1:133 1st degree relatives: 1:18 to 1:22 2nd degree relatives: 1:24 to 1:39 Fasano, et al, Arch of Intern Med, Volume 163: 286-292, 2003

Prevalence of Celiac Disease is Higher in Other Autoimmune Conditions Type 1 Diabetes Mellitus: 3.5 - 10% Thyroiditis: 4 - 8% Arthritis: 1.5 - 7.5% Autoimmune liver diseases: 6 - 8% Sjögren’s syndrome: 2 - 15% Idiopathic dilated cardiomyopathy: 5.7% IgA nephropathy: 3.6%

Which Came First?

Celiac Disease and Autoimmunity Prevalence of autoimmune disorders in celiac disease related to duration of gluten exposure Diagnosed before 2 years of age: 5% Age 2-10 years: 17% Greater than age 10 years: 24% Increased incidence of autoimmune disease in patients with IDDM and ‘silent’ Celiac Disease and their first degree relatives who were EMA+ Ventura et al, Gastro 1999; Not , Diabetologia 2001

Pathogenesis Genetic predisposition Environmental triggers Dietary Non dietary?

Pathogenesis Necessary Causes Risk Factors Genetics Gluten Gender Infant feeding Infections Others Pathogenesis ? Risk Factors Celiac disease

Genetics Several genes are involved The most consistent genetic component depends on the presence of HLA-DQ (DQ2 and / or DQ8) genes Other genes (not yet identified) account for 60 % of the inherited component of the disease HLA-DQ2 and / or DQ8 genes are necessary (No DQ2/8, no Celiac Disease!) but not sufficient for the development of the disease Genes ? ? ? ? HLA + Gluten Celiac Disease

Dietary Factors Gluten Gliadin Glutenin Wheat - (15% protein, 75% starch) Rye prolamines - secalins Barley prolamines - hordeins ? Oats prolamines - avenins Gluten Gliadin (alcohol soluble) Prolamine Glutenin (alcohol insoluble)

Non Dietary Factors Infections Viral infections sequence homology between a-gliadin & adenovirus type 12 & 7, rubella and human herpesvirus 1 Parasitic infestations sequence homology between a-gliadin & Plasmodium yoelli Other ?

The Celiac Iceberg Symptomatic Celiac Disease Manifest mucosal lesion Silent Celiac Disease Latent Celiac Disease Normal Mucosa Genetic susceptibility: - DQ2, DQ8 Positive serology

Clinical Manifestations Gastrointestinal (“classical”) Non-gastrointestinal ( “atypical”) Asymptomatic In addition, Celiac Disease may be associated with other conditions, and mostly with: Autoimmune disorders Some syndromes

Gastrointestinal Manifestations (“Classic”) Most common age of presentation: 6-24 months Chronic or recurrent diarrhea Abdominal distension Anorexia Failure to thrive or weight loss Rarely: Celiac crisis Abdominal pain Vomiting Constipation Irritability

Typical Celiac Disease

Recurrent Aphtous Stomatitis By permission of C. Mulder, Amsterdam (Netherlands)

Non Gastrointestinal Manifestations Most common age of presentation: older child to adult Dermatitis Herpetiformis Dental enamel hypoplasia of permanent teeth Osteopenia/Osteoporosis Short Stature Delayed Puberty Iron-deficient anemia resistant to oral Fe Hepatitis Arthritis Epilepsy with occipital calcifications Listed in descending order of strength of evidence

Dermatitis Herpetiformis Erythematous macule > urticarial papule > tense vesicles Severe pruritus Symmetric distribution 90% no GI symptoms 75% villous atrophy Gluten sensitive Garioch JJ, et al. Br J Dermatol. 1994;131:822-6. Fry L. Baillieres Clin Gastroenterol. 1995;9:371-93. Reunala T, et al. Br J Dermatol. 1997;136-315-8.

Dermatitis Herpetiformis By permission of C. Mulder, Amsterdam (Netherlands)

Dental Enamel Defects Involve the secondary dentition This slide demonstrates some of the subtle dental enamel defects that can be seen in a patient with celiac disease. The enamel defects occur in the secondary dentition, which is forming in the gums when a child begins to ingest gluten. The enamel defects are vertical lines which can be seen as notches or linear defects in the teeth in all four quadrants. These patients are at increased risk for caries in unusual locations. Sealants may be protective. Involve the secondary dentition May be the only presenting sign of Celiac Disease

Low bone mineral density improves in children on a gluten-free diet. Osteoporosis Osteomalacia in a celiac patient showing pseudofractures of the pelvis (arrows). Patient was 45 years old and presented with bone pain and proximal muscle weakness (for over 2 years) in the absence of overt GI symptoms. Elevated alkaline phosphatase and absence of Vitamin D stores were seen. Low bone mineral density improves in children on a gluten-free diet.

Short Stature/Delayed Puberty Short stature in children / teens: ~10% of short children and teens have evidence of celiac disease Delayed menarche Higher prevalence in teens with Untreated Celiac Disease

Fe-Deficient Anemia Resistant to Oral Fe Most common non-GI manifestation in some adult studies 5-8% of adults with unexplained iron deficiency anemia have Celiac Disease In children with newly diagnosed Celiac Disease:  Anemia is common  Little evidence that Celiac Disease is common in children presenting with anemia

Hepatitis Some evidence for elevated serum transaminases (ALT, AST) in adults with untreated Celiac Disease  Up to 9% of adults with elevated ALT, AST may have silent Celiac Disease  Liver biopsies in these patients showed non- specific reactive hepatitis  Liver enzymes normalized on gluten-free diet

Arthritis and Neurological Problems Arthritis in adults Fairly common, including those on gluten-free diets Juvenile chronic arthritis Up to 3% have Celiac Disease Neurological problems Epilepsy with cranial calcifications in adults Evidence for this condition in children with Celiac Disease is not as strong

Celiac Disease Complicated by Enteropathy-Associated T-cell Lymphoma (EATL) By permission of G. Holmes, Derby (UK)

3 – Asymptomatic Silent Latent Silent: No or minimal symptoms, “damaged” mucosa and positive serology Identified by screening asymptomatic individuals from groups at risk such: First degree relatives Down syndrome patients Type 1 diabetes patients, etc.

3 – Asymptomatic Silent Latent Latent: No symptoms, normal mucosa May show positive serology. Identified by following in time asymptomatic individuals previously identified at screening from groups at risk. These individuals, given the “right” circumstances, will develop at some point in time mucosal changes (± symptoms)

Diagnosis Diagnosis of Celiac Disease requires: characteristic small intestinal histology in a symptomatic child complete symptom resolution on gluten-free diet Serological tests may support diagnosis Select cases may need additional diagnostic testing The European Society for Pediatric Gastroenterology and Nutrition has published recommendations for the diagnosis of celiac disease. The diagnosis in a symptomatic individual requires demonstration of the characteristic histopathological changes of celiac disease on small intestinal biopsy with subsequent complete symptom resolution on a gluten free diet. A positive serological test before starting treatment, that disappears after a period of some months after starting therapy, is further supportive evidence for the diagnosis. In a study of over 3800 individuals with celiac disease it was found that these criteria were sufficient to confirm the diagnosis in over 95% of cases without the need for additional biopsies. In a few cases, particularly in the young child under two years of age, it may still be necessary to revert to the old three biopsy protocol to confirm the diagnosis. ESPGAN working group. Arch Dis Child 1990;65:909

Serological Tests Antigliadin antibodies (AGA) Antiendomysial antibodies (EMA) Anti tissue transglutaminase antibodies (TTG) first generation (guinea pig protein) second generation (human recombinant) HLA typing Commercially available tests for celiac disease include the antigliadin, anti endomysial and anti tissue-transglutaminase tests. Tissue transglutaminase has been identified as the auto-antigen in celiac disease against which endomysial antibodies are directed. Initial transglutaminase tests used guinea pig protein as the antigen. Cloning of the gene for human transglutaminase has allowed for tests using human recombinant protein. In addition to antibody tests, some commercial laboratories are offering tests to identify the HLA DQ2 and DQ8 genotypes that are known to be strongly associated with celiac disease.  

Antigliadin Antibodies Antibodies (IgG and IgA) to the gluten protein in wheat, rye and barley Advantages relatively cheap & easy to perform Disadvantages poor sensitivity and specificity Antigliadin antibodies were the earliest tests developed for use in celiac disease. They are directed against the gliadin fraction of the gluten protein found in wheat. Both an IgA and an IgG based antibody are available. The advantages of the antigliadin tests are that they are relatively cheap and easy to perform. The major disadvantage is that they are relatively poorly sensitive and specific.

Endomysial Antibody - EMA IgA based antibody against reticulin connective tissue around smooth muscle fibers Advantages high sensitivity and specificity Disadvantages false negative in young children operator dependent expensive & time consuming false negative in IgA deficiency Endomysial antibodies are IgA based and directed against the reticulin connective tissue around smooth muscle fibers. The test is performed by means of an indirect immunofluorescent assay using monkey esophagus or human umbilical cord as substrate. Either substrate is equally effective. The advantage of this test is that it is highly sensitive and specific. The disadvantages include the fact that it is operator dependent and hence potentially prone to errors in interpretation, it is generally more time consuming to perform and thus more expensive and it does not allow detection of celiac disease in individuals with selective IgA deficiency.

Tissue Transglutaminase (TTG) Normal gut enzyme released during injury and stabilizes the cross-linking of proteins in granulation tissue Role in Celiac Disease Modification of gliadin epitopes Autoantibodies against TTG correlate with active Celiac Disease - ? involved in pathogenesis

Tissue Transglutaminase - TTG IgA based antibody against tissue transglutaminase (Celiac Disease autoantigen) Advantages high sensitivity and specificity (human TTG) non operator dependent (ELISA/RIA) relatively cheap Disadvantages false negative in young children false negative in IgA deficiency possibly less specific than EMA The tissue transglutaminase test is IgA based and performed by means of either an ELISA or RIA technique. The major advantages of the test are that it is highly sensitive and specific, is non operator dependent and is relatively cheap to perform. The disadvantages are that it is unable to detect celiac disease in IgA deficient individuals and it may be less specific than the endomysial antibody.

Serological Test Comparison Sensitivity % Specificity % AGA-IgG 69 – 85 73 – 90 AGA-IgA 75 – 90 82 – 95 EMA (IgA) 85 – 98 97 – 100 TTG (IgA) 90 – 98 94 – 97 This slide summarizes the sensitivities and specificities for the various antibody tests. Farrell RJ, and Kelly CP. Am J Gastroenterol 2001;96:3237-46.

HLA Tests HLA alleles associated with Celiac Disease DQ2 found in 95% of celiac patients DQ8 found in remaining patients DQ2 found in ~30% of general population Value of HLA testing High negative predictive value Negativity for DQ2/DQ8 excludes diagnosis of Celiac Disease with 99% confidence The role of HLA testing in celiac disease needs to be addressed. It is known that over 95% of all individuals with celiac disease are HLA DQ2 positive and virtually all the rest are positive for the HLA DQ8 genotype. However, about 30% of the general population is also HLA DQ2 positive. Thus, while these tests will likely demonstrate a high degree of sensitivity for celiac disease, they will be poorly specific. In contrast, knowing an individual is neither HLA DQ2 nor DQ8 positive may be helpful to the clinician as this almost completely eliminates the possibility the individual has celiac disease. Schuppan. Gastroenterology 2000;119:234 Kaukinen. Am J Gastroenterol 2002;97:695

HLA Tests Potential role for DQ2/DQ8 asymptomatic relatives Down, Turner & Williams syndrome type 1 diabetes diagnostic dilemmas Determining the HLA type may be of benefit in some asymptomatic individuals with negative serological antibody tests who belong to a group considered at increased risk for celiac disease. These include individuals who are relatives of a confirmed case of celiac disease and those with Down syndrome, Turner syndrome or William syndrome and type 1 diabetes. It is known that some such individuals with initial negative serological tests will subsequently become positive and have biopsy changes compatible with celiac disease over a period of time if testing is repeated at intervals. Knowing an individual belonging to one of these groups was negative for both HLA DQ2 and DQ8 enables the physician to reassure them there is no further need to test them for celiac disease. HLA typing for the celiac disease haplotypes may also help in some cases where the diagnosis is not clear, either because the individual never had a biopsy prior to starting treatment or because the histological features are not difficult to interpret. Once again, in these cases the absence of either of the HLA types virtually eliminates the likelihood of celiac disease in the individual.

Endoscopic Findings Scalloping Normal Appearing Scalloping Nodularity A small intestinal biopsy and histological evaluation for the characteristic changes of celiac disease remains an essential component for confirming the diagnosis. Most biopsies today are obtained by means of an upper GI endoscopy with intubation of the duodenum. There are some macroscopical that are suggestive of celiac disease including a scalloped appearance along the duodenal folds and mucosal nodularity as shown in this slide. However, these findings are by no means reliable and mucosal biopsies are always needed. Normal Appearing Scalloping Nodularity

Not recommended for initial diagnosis Fantastic Voyage Not recommended for initial diagnosis Celiac Normal

Patterns of Mucosal Immunopathology Type 0 Type 1 Type 2 Type 3 Normal Celiac Diseae (latent) Infilitrative Celiac Giardiasis Milk intolerance Tropical sprue Marasmus GVHR Hyper plastic Celiac Giardiasis Milk intolerance Tropical sprue Marasmus GVHR Flat destructive Celiac Giardiasis Milk intolerance Tropical sprue Marasmus GVHR Marsh has described a progression of changes in the small intestinal mucosa. The earliest changes involve an increased mucosal cellular infiltrate, and in particular there is an increase in the number of intra-epithelial lymphocytes (Marsh type 1 or infiltrative stage). The next step is progressive elongation of the intestinal crypts (Marsh type II or hyperplastic stage) superimposed on the increased cellular infiltrate. The final step is progressive flattening of the intestinal villi superimposed on the cellular infiltrate and crypt hyperplasia (Marsh type III or destructive stage). While the histological changes, and in particular the Marsh type III changes, are characteristic for celiac disease they are by no means pathognomonic and may also be seen with other conditions. It is the constellation of clinical features, histological findings, response to therapy and serological findings that ultimately enable a confident diagnosis of confirmed celiac disease. Marsh, Gastroenterology 1992, Vol 102: 330-354

Treatment Only treatment for celiac disease is a gluten-free diet (GFD) Strict, lifelong diet Avoid: Wheat Rye Barley

How much exposure is safe? Complete gluten avoidance is extremely difficult Exposure to trace amounts of gluten common even if product is sold as NATURALLY gluten-free Safe threshold for gluten exposure = 10-100 mg Daily intake 30 mg of gliadin seems not to harm the intestinal mucosa Amount of residual gluten in gluten-free products and the total intake of these products must be considered

50 mg gluten

Gluten-Containing Grains to Avoid Wheat Bulgar Filler Wheat Bran Couscous Graham flour Wheat Starch Durum Kamut Wheat Germ Einkorn Matzo Flour/Meal Barley Emmer Semolina Barley Malt/ Extract Faro Spelt Rye Triticale

Sources of Gluten OBVIOUS SOURCES Bread Bagels Cakes Cereal Cookies Pasta / noodles Pastries / pies Rolls

Sources of Gluten POTENTIAL SOURCES Candy Communion wafers Cured Pork Products Drink mixes Gravy Imitation meat / seafood Sauce Self-basting turkeys Soy sauce

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

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