A.M. Report 5/5/09 Jason Haag, M.D. Celiac Disease A.M. Report 5/5/09 Jason Haag, M.D.

Celiac Disease What is it? Small bowel disorder characterized by Mucosal inflammation Villous atrophy Crypt hyperplasia That occur with exposure to gluten and improve with its withdrawal

Associated Condition’s Dermatitis herpetiformis Down’s Syndrome IgA Deficiency DM type I Thyroid disease Autoimmune hepatitis

Whom to test? Chronic GI Sx Nutritional disorders Diarrhea, malabsorption, weight loss, abdominal distention Nutritional disorders Elevated liver enzymes, delayed puberty, Fe-def anemia, recurrent fetal loss, infertility, ? Osteoporosis (2/2 Vit D def)

Whom to test? High Risk Pt Asymptomatic individuals DM type I, autoimmune d/o, 1st/2nd degree related w/ Celiac dx Asymptomatic individuals No benefit to screening

How to test? First – make sure Pt is on a gluten-containing diet If already on gluten free diet then test after 2-4 weeks of resuming gluten-containing diet Low probability Serological testing IgA anti tissue transglutaminase (sens 90%, spec 95%) IgA endomysial antibody (sens 90%, spec 97%) Antigliadin antibody no longer in routine use (sens 80%, spec 85%) 2nd generation test in development

How to test? High probability Serological testing as before Small bowel biopsy Duodenal mucosa appears atrophic with loss of folds, contian visible fissures, and may have nodular appearance

How to test? If patient has clinical features, but negative serology Consider IgA deficiency Can test for IgG EMA or tTG Perform small bowel biopsy Test for HLA type 99% of patients with celiac have DQ2 and DQ8 types compared to 40% of general population Consider other diagnosis

Treatment Gluten-free diet “Safe” foods Careful with lactose foods High sources of gluten Wheat, rye, barley, oats “Safe” foods Soybeans, rice, corn, potatoes Careful with lactose foods May worsen symptoms as many with celiac disease have lactose intolerance

Prevention Osteoporosis Hyposplenism Vitamin Def DEXA scan Pneumovax Iron, folate, calcium vitamin D, B12

Monitoring Response Can follow serial IgA tTG Check approx 6 months to 1 year after initiation of gluten free diet Only works if antibody level elevated prior to therapy Debate over repeat small bowel biopsy If preformed usually at 3 months after gluten free diet If no improvement with glute-free diet can consider a gluten challenge and follow symptoms

Take Home Points Test with IgA anti tissue transglutaminase, IgA endomysial antibody Association with Dermatitis herpetiformis and IgA deficiency Always test on gluten laden diet

References Rostom, A, et al. Celiac Disease. Summary, evidence report. Agency for Healthcare Research and Quality, Rockville, MD 2004 Kelly, CP et al. Diagnosis and treatment of gluten-sensitive enteropathy. Adv Intern Med 1990; 35: 341. Green, PH, Cellier, C. Celiac Disease. NEJM 2007; 357:1731 Uptodate.com