Happy New Year to all of you!
This post will focus on updated information about adult celiac disease that was presented at the Celiac Disease preceptorship that I attended at the University of Chicago in December 2014. Prior to the hustle and bustle of the holidays I was able to write a bit about what I learned about pediatric celiac disease (see link). I hope to share more information from the preceptorship in upcoming months, as time allows…
Dr. Carol Semrad, a celiac specialist from the Celiac Disease Center at the University of Chicago, gave a presentation entitled “Celiac Disease: The Adult Perspective” on December 4th. Here are some of the “highlights” from her excellent and comprehensive lecture.
75% of patients with celiac disease are diagnosed during the adult years. Many have only mild, intermittent gastrointestinal (GI) symptoms that they may think are “normal.” Many adults are actually overweight/obese at the time of diagnosis. Others may have other problems (with either mild or absent GI symptoms) such as low bone mineral density, iron deficiency anemia, and hepatitis.
Celiac disease can present in 4 different ways:
1. Classical: diarrhea, gas/bloating, and weight loss
2. Atypical: fatigue, constipation, anemia, osteoporosis, dermatitis herpetiformis (rash), neuropathy, infertility, etc.
3. Asymptomatic: No symptoms, but positive celiac antibodies and an abnomal small bowel biopsy
4. Potential (latent): No symptoms, positive celiac antibodies but normal small bowel biopsy
The incidence of classical celiac disease is 1:4500, but the incidence of atypical, asymptomatic, and latent is 1:133. Celiac disease is not a rare disease like so many of us were taught during medical school.
The duodenal biopsy remains important for celiac disease diagnosis in adults and must be performed prior to a patient starting on a gluten-free diet. As discussed elsewhere during the conference, a “gluten challenge” in adults consists of eating at least 1/2 slice of bread for 2 weeks prior to a small bowel biopsy (and 6 weeks prior to celiac blood antibody testing).
Although villous blunting is the hallmark of celiac disease on small bowel biopsy, there are other diseases that can also cause villous blunting, which include tropical sprue, infections (Giardia, Cryptosporidia), Crohn’s Disease, small bowel bacterial overgrowth, olemsartan enteropathy, autoimmune enteropathy, and Graft v. Host Disease. Villous recovery will occur on the gluten-free diet in celiac disease only (this can be used to differentiate celiac disease from the other causes of villous blunting).
Dr. Semrad recommended that patients with any of the following problems be tested for celiac with a duodenal biopsy:
-Diarrhea with weight loss
-Unexplained iron deficiency anemia
-Neuropathy or ataxia
-Positive celiac antibody tests prior to going on the GF diet
“High-Risk” patients who should have screening celiac antibody tests performed include those who have any of the following:
-First degree relatives of those with celiac (parents, siblings, and children)
-Type 1 diabetes
-Autoimmune thyroid disease
-Irritable Bowel Syndrome
-Primary Biliary Cirrhosis
-Down, Turner, and William’s syndromes
Treatment for celiac disease should include all of the following:
1. Life-long, strict gluten-free diet, including consultation with a dietician who is knowledgable about celiac disease
2. Lactose-free diet to start
3. Daily multivitamin and calcium
4. Folic acid for all women of child-bearing age
Patients with newly diagnosed celiac disease should follow-up with their physician and dietician at 3-6 months, and then every 1-2 years. Celiac antibodies should be retested after 3-12 months on the GF diet. Despite this, only 44% of newly diagnosed celiacs in the U.S. follow-up with their physicians, and only 3% have any follow-up with a dietician!
80% of patients with celiac disease will start to have improvement within 2 weeks of starting the GF diet. 20% will not have improvement at the 6 month mark and will be ultimately be diagnosed with nonresponsive celiac disease. Ongoing gluten ingestion is the most common cause of nonresponsive celiac disease. I’ll discuss both nonresponsive and refractory celiac disease in more detail in an upcoming post. The bottom line is that if one continues to have symptoms after going on the GF diet, that follow-up is necessary.
Thank you for reading, and as always, please feel free to comment, ask questions, etc. Also, as an aside, please check out the January/February 2015 issue of Gluten-Free Living Magazine. I am featured in Susan Cohen’s article, “It’s Routine,” along with some other really cool celiac advocates including Dr. Fasano.