1. Celiac Disease and tropical sprue

2. Celiac disease
Inappropriate immune response to the dietary protein gluten, which is found in rye, wheat, and barley.
After absorption in the small intestine these proteins interact with the antigen-presenting cells in the lamina propria causing an inflammatory reaction that targets the mucosa of the small intestine.
Manifestations range from no symptoms to overt malabsorption with involvement of multiple organ systems and an increased risk of some malignancies.
Not completely understood how gluten sensitivity begins or whether early exposure to gluten proteins increases the risk of sensitivity

3. Most all patients with celiac disease express (HLA)-DQ2 or HLA-DQ8, which facilitate the immune response against gluten proteins
Concordance rates of 70 to 75 % among monozygotic twins and 5 to 22 % among first-degree relatives.

4. Signs and Symptoms Uncommon Common Osteopenia/ osteoporosis
Abnormal liver function
Vomiting
Iron-deficiency anemia
Neurologic dysfunction
Constipation
Nausea
Common
Diarrhea
Fatigue
Borborygmus
Abdominal pain
Weight loss
Abdominal distention
Flatulence
Up to 38 % Asymptomatic

5. Celiac Disease: Associated Disorders
Dermatitis Herpetiformis
Iron deficiency anemia
Osteoporosis, Osteomalacia and Vitamin D deficiency
Malignancies
Type 1 diabetes
Other autoimmune endocrine disorders
Neuropsychologic Features
Others (Downs syndrome, IgA deficiency, rheumatologic disorders)

6. Celiac Disease: Dermatitis Herpetiformis
Symmetric vesicles, crusts and erosions distributed over the extensor areas of the elbows, knees, buttocks, shoulders and scalp, with a tendency to grouping of individual lesions.
PRUESSNER, HT. Detecting Celiac Disease in Your Patients by the American Academy of Family Physicians
University of Texas Medical School at Houston

7. 30 to 40 (w/o gluten free diet)
Celiac Disease: Malignancies
Malignancy 
Overall Relative Risk
All cancers
2 to 3
Enteropathy -associated T-cell lymphomas
30 to 40 (w/o gluten free diet)
Small intestinal adenocarcinoma 83
Mouth, pharynx, esophagus cancer
23 (w/o gluten free diet)
American Gastroenterological Association, Ciclitra, PJ, Gastroenterology 2001; 120: 1526.

8. Celiac Disease: Other Associated Disorders
Aphthous stomatitis- unexplained oral ulcers have been reported as the sole presenting feature
Glossitis, angular stomatitis, and cheilosis have also been associated

9. Diagnosis of Celiac Disease
Clinical Findings
Small Intestines Mucosal Biopsy
Gluten Re-challenge
Serologic testing

10. Diagnosis: Small Bowel Endoscopy
Normal
Celiac

11. Histologic Findings of Celiac
Normal Jejunum
Celiac
Virginia Commonwealth Univ, Richmond, Virginia Celiac Disease (Gluten-Induced Enteropathy) F2923

12. Histologic Findings of Celiac
The lamina propria shows a marked increase in the number of plasma cells and lymphocytes and transepithelial migration of lymphocytes across the surface epithelium (arrow) is common.
Virginia Commonwealth Univ, Richmond, Virginia Celiac Disease (Gluten-Induced Enteropathy) F2923

13. Other Causes of Villous Atrophy
Bacterial Overgrowth
Crohn’s disease
Cow’s milk protein intolerance (children)
Eosinophilic gastroenteritis
Giardiasis
Lymphoma
Post gastroenteritis
Tropical sprue
Zollinger Ellison syndrome
American Gastroenterological Association, Ciclitra, PJ, Gastroenterology 2001; 120: 1526.

14. Diagnosis of Celiac: Serologic Testing
IgA antigliadin antibodies
Sensitivity 80 to 90 %
Specificity 85 to 95 %
IgA endomysial antibodies
Sensitivity 85 to 98 %
Specificity 97 to 100 %
IgA tissue transglutaminase antibodies
Sensitivity 90 to 98 %
Specificity 95 to 97 %
Kelly, CP. Coeliac disease: Non-invasive tests to screen for gluten sensitive enteropathy and to monitor response to dietary therapy. Dublin University, Trinity College, Dublin 1995.
Kelly, CP, Feighery, CF, Gallagher, RB, et al. Mucosal and systemic IgA anti-gliadin antibody in celiac disease. Contrasting patterns of response in serum, saliva, and intestinal secretions. Dig Dis Sci 1991; 36:743.

15. Management of Celiac Disease
Gluten avoidance is the mainstay of treatment
Prior to the introduction of a strict gluten-free diet, prognosis was very poor

16. Management of Celiac Disease
In general, the following advice can be given to all patients:
Foods containing wheat, rye, and barley should be avoided.
Soybean, rice, corn, and potatoes are safe.
Read labels on prepared foods carefully (many stabilizers or emulsifiers contain gluten)
Dairy products may need to be avoided initially- many patients have secondary lactose intolerance.

17. Foods That May Contain Gluten
Bouillon Cubes
Canned soups
Cheese spreads
Chips and dips mixes
Hot chocolate mixes or cocoa
Ice cream
Meat sauces
Peanut butter
Processed canned meats and poultry
Soup mixes
Tomato sauces
Sausages
Yogurt with fruit

18. Monitoring Adherence by Serologic Testing
A pretreatment antibody level should be determined at the time of diagnosis.
Serologic testing is of no use if antibody levels are not elevated prior to therapy.
Exclusion of gluten from the diet results in a gradual decline in serum IgA antigliadin and IgA tTG levels.
A normal baseline value is typically reached within three to six months.
If the levels do not fall as anticipated, the patient may be continuing to ingest gluten either intentionally or inadvertently

19. Patients unresponsive to gluten-free diet
. -Poor dietary compliance
-Coexistent irritable bowel syndrome
-Microscopic colitis
-Lactase deficiency
-Small intestinal bacterial overgrowth Lymphoma
-Refractory sprue

20. What is the tropical sprue?
Tropical sprue: is a malabsorption disease
commonly found in the tropical regions,
marked with abnormal flattening of the villi
and inflammation of the small intestinal
mucosa.

21. Causes No specific causal agent has been clearly
associated with tropical sprue, but
bacterial overgrowth by enterotoxigenic
organisms ( e.g., E.coli and hemophilus )
has been implicated.

22. Morphology
Intestinal changes range from near normal to severe diffuse enteritis.
Unlike celiac sprue, injury is seen at all levels of the small intestine.

23. Symptoms The symptoms of tropical sprue are: - Diarrhea.
- Indigestion.
- Cramps.
- Weight loss and malnutrition.
- Fatigue.

24. Investigations:
Low levels of vitamins A, D, E, K, and B12
as well as albumin, calcium, and folate.
Excess fat in feces

25. Treatment:-
3 to 6 months of antibiotics (tetracycline) and folic acid supplements.