Celiac disease in Slovenia University medical centre Maribor Dušanka Mičetić Turk, Miroslav Palfy, Jernej Dolinšek

University medical centre Maribor Pediatric Department

Republic of Slovenia Location: Central Europe, bordering the Mediterranean Government: Parliamentary republic Capital: Ljubljana Area: 20,273 km² Population: 2,053,684 ‏ GDP (2009): € 34.894 million GDP per capita: € 17,092 Source: upload.wikimedia.org

Population age structure

Diagnostic centres for CD in Slovenia University Medical Centre Ljubljana (for adults and children)‏ University Medical Centre M aribor (for adults and children)‏ Celje (adults)‏ Koper (adults)‏ Novo Mesto (adults)‏ Murska Sobota (adults)‏ Slovenj Gradec (adults)‏ Bled (adults)

Diagnostic tests Serology - quick t-TG test Genetics - HLA DQ2/DQ8 - EMA - t-TG - total IgA Genetics - HLA DQ2/DQ8 Small bowel biopsy - endoscopy/4-5 biopsy specimens (duodenum) Histology - Marsh/Oberhubner classification Immunohistochemistry - apoptotic index - proliferation index - α/β and γ/δ receptors

Patient presents with symptoms of celiac disease Perform serologic IgA tTG antibody testing Positive result Negative result Small bowel biopsy High clinical suspicion for CD? No Yes Positive Negative Low probability of CD; consider total IgA test to rule out IgA deficiency Small bowel biopsy Dg confirmed, Gluten-free diet Follow up and consider other dg, consider repeat biopsy Positive Negative Treat as CD and monitor CD eliminated, look for other causes Improvement? Yes No Dg confirmed Evaluate for possible secondary cause of symptoms

Epidemiology

Cumulative incidence of celiac disease by birth cohort in NE Slovenia Maribor Celje LB N CI 1975 4603 3 0,651749 1976 4601 4 0,760539 1977 4543 0,509202 1978 4562 5 0,655415 1979 4567 0,699423 2978 2 0,671592 1980 4421 6 0,805949 2879 0,682943 1981 4479 9 0,975579 2678 0,702988 1982 4296 1,025726 2456 0,909835 1983 4089 1,07069 2890 0,936532 1984 3986 13 1,268489 2768 1 0,840891 1985 3950 1,434601 2689 0,827386 1986 3712 7 1,466927 2743 0,996332 1987 3611 12 1,587874 1,009734 1988 3676 14 1,726005 2567 1,171046 1989 3437 1,727088 2724 1,198003 1990 3273 1,732365 2679 1,283266 1991 3218 1,83994 2506 1,30552 1992 3048 1,776002 2379 1,462222 1993 2888 1,760939 2420 1,523705 1994 2954 11 1,835357 2426 1,507301 1995 2811 1,783834 2208 1,477568 1996 2900 1,80568 2246 1,428145 1997 2550 1,798666 2835 1,386963 1998 2589 1,757469 2797 1,332166 1999 3468 1,723914 1840 1,305483 2000 3634 1,710721 1815 1,263323 2001 3596 1,689087 1753 1,242365 2002 1,668963 1817 1,221328 2003 3661 1,63045 1660 1,220882 2004 3619 1,631351 1719 1,203484 2005 3709 1,61337 1747 1,248132 2006 3731 1,579242 1918 8 1,332036 2007 3654 1,581132 2015 1,409269 2008 4184 1,576232 2237 1,435265 2009 4116 1,54164 2119 1,407373

Clinical symptoms in children at diagnosis 1975-1999 2000-2009 Chronic diarrhoea 70 31 Abdominal distension 50 26 Weight loss 48 20 Growth failure 30 17 Edema 8 3 Celiac disease in siblings 13 Obstipation 5 18 Pallor 2 Vomiting

Clinical symptoms in children (%)‏ 10 20 30 40 50 60 abdominal distension chronic diarrhoea abdominal pain anemia inapetention failure of thrive vomiting obstipation asthma without symptoms resistent anemia skin disorders growth failure edema alopetia areata osteopenia Down syndrom AI thyroiditis arthralgiae Maribor Celje

Age at diagnosis (years)‏ Age of children at diagnosis (1999-2009)‏ Gender Number Age at diagnosis (years)‏ Boys 30 1.96 ± 2.11 Girls 42 2.60 ± 2.01 Total 72 2.54 ± 2.02

Slovene celiac society Established in 1988 in Maribor Network of 8 branches (one in each region) cover whole Slovenia 1500 members (children and adults)‏ Activities for members: summer camps with rehabilitation and school baking courses lectures trips support meetings newspaper “Celiakija” webpage, Facebook group

GFD availability and state support GF products are available in all bigger supermarkets (all chains have GF products in assortiment – Schär, La Veneziane, Orgran, Klasje…)‏ Restaurant with GF food in each city Monthly support of €80 for parents of children with CD Tax reductions for parents No support for adults

Future