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Questions and Answers
What is the name for the specific proteins found in wheat, barley, and rye that cause the symptoms of celiac disease?
What is the name for the specific proteins found in wheat, barley, and rye that cause the symptoms of celiac disease?
Prolamins
Celiac disease is a disorder that only affects the small intestine, while leaving other parts of the body unaffected.
Celiac disease is a disorder that only affects the small intestine, while leaving other parts of the body unaffected.
False (B)
What percentage of celiac disease cases are estimated to be undiagnosed or misdiagnosed?
What percentage of celiac disease cases are estimated to be undiagnosed or misdiagnosed?
60
What is the typical range of age at which celiac disease is diagnosed?
What is the typical range of age at which celiac disease is diagnosed?
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Most cases of celiac disease are diagnosed in childhood.
Most cases of celiac disease are diagnosed in childhood.
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What is the common skin condition associated with celiac disease?
What is the common skin condition associated with celiac disease?
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Patients with dermatitis herpetiformis always present with gastrointestinal symptoms related to celiac disease.
Patients with dermatitis herpetiformis always present with gastrointestinal symptoms related to celiac disease.
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What is the gold standard for confirming a diagnosis of celiac disease?
What is the gold standard for confirming a diagnosis of celiac disease?
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It is recommended to reduce your gluten intake prior to any celiac disease testing.
It is recommended to reduce your gluten intake prior to any celiac disease testing.
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What is the cornerstone of treatment for celiac disease?
What is the cornerstone of treatment for celiac disease?
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Products labeled as 'wheat-free' are always also gluten-free.
Products labeled as 'wheat-free' are always also gluten-free.
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Oats are generally safe for individuals with celiac disease.
Oats are generally safe for individuals with celiac disease.
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A gluten-free diet automatically eliminates the need for additional vitamin and mineral supplements.
A gluten-free diet automatically eliminates the need for additional vitamin and mineral supplements.
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Celiac patients should avoid consuming any dairy products.
Celiac patients should avoid consuming any dairy products.
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It is recommended to avoid all foods containing wheat.
It is recommended to avoid all foods containing wheat.
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Flashcards
Celiac Disease (CD)
Celiac Disease (CD)
A genetic, immune disorder where gluten damages the small intestine lining.
Gluten
Gluten
Proteins, prolamins, found in wheat, barley, and rye.
Diagnosis Delay
Diagnosis Delay
Average time from symptom onset to diagnosis is 11 years.
Gluten-Free Diet
Gluten-Free Diet
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Small Intestine Damage
Small Intestine Damage
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Malabsorption
Malabsorption
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Diarrhea
Diarrhea
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Dermatitis Herpetiformis
Dermatitis Herpetiformis
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Serologic Markers
Serologic Markers
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Intestinal Mucosal Biopsy
Intestinal Mucosal Biopsy
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Intraepithelial Lymphocytes
Intraepithelial Lymphocytes
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Crypt Hyperplasia
Crypt Hyperplasia
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Villous Atrophy
Villous Atrophy
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Hidden Gluten
Hidden Gluten
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Cross-Contamination
Cross-Contamination
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Secondary Lactose Intolerance
Secondary Lactose Intolerance
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Gluten-Free Grains
Gluten-Free Grains
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Dietary Fiber
Dietary Fiber
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Iron-Deficiency Anemia
Iron-Deficiency Anemia
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Vitamin Supplements
Vitamin Supplements
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Weight Loss
Weight Loss
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Study Notes
Celiac Disease Overview
- Celiac disease, also known as non-tropical sprue, celiac sprue, or gluten-sensitive enteropathy (CD), is a genetically determined, immune-mediated disorder.
- Gluten, a protein found in wheat, barley, and rye, damages the lining of the small intestine in individuals with CD.
- Approximately 60% of cases are undiagnosed or misdiagnosed with other conditions such as irritable bowel syndrome (IBS), lactose intolerance, or inflammatory bowel disease (IBD).
- Diagnosis is often delayed for an average of 11 years.
- Removing gluten from the diet improves clinical and histological symptoms, but reintroduction of gluten causes villus damage to relapse.
Introduction
- Gluten is the name for specific proteins in wheat, barley, and rye called prolamins.
Complications
- Untreated celiac disease can lead to life-threatening complications and increased mortality risk.
- Patients with CD are at increased risk of enteropathy-T-cell lymphoma or carcinoma of the oropharynx, esophagus, and small intestine.
- First-degree relatives and individuals with diabetes mellitus (DM) should be screened for CD.
Clinical Presentation
- Age at presentation ranges from 6 months to over 85 years, with a higher proportion of cases diagnosed in adulthood (20% after 60 years old).
- Infants usually develop symptoms between 4-24 months of age, following the introduction of cereals into their diet.
- Manifestations include impaired growth, diarrhea, and abdominal distention.
- Weight loss in children may occur if untreated, leading to short stature, iron deficiency anemia (IDA), and delayed puberty, rickets.
- In adults, symptoms may include malabsorption (diarrhea, steatorrhea), anemia, vitamin deficiencies, and weight loss (with some having significant diarrhea, while some experiencing no malabsorption).
- Additional symptoms in the case of partial villi atrophy can include fatigue, depression, arthralgia, milk intolerance, osteomalacia, and osteoporosis.
- There may be a delay between the clinical presentation and the diagnosis of celiac disease, often misdiagnosed as Irritable Bowel Syndrome (IBS).
- Pregnancy or the postpartum period can sometimes present as a time of onset of symptoms, particularly if severe anemia develops.
- Dermatitis herpetiformis, a skin rash, can be the only symptom in 5% of CD patients (15-40 years old). The rash commonly appears on pressure points, and it has the potential to present alongside gastrointestinal symptoms. It is treatable by dapsone and a gluten-free diet, with improvement typically taking 6-24 months.
Diagnostic Approach
- Laboratory tests may reveal abnormalities in iron, folate, calcium, vitamin A, D, E, K, and B12, necessitating further testing.
- Blood counts may show anemia, target cells, and Howell-Jolly bodies (hyposplenism).
- Serological markers are considered the best non-invasive tests; these include IgA antiendomysial antibody, IgA and IgG antigliadin antibodies, and tissue transglutaminase antibody (most important single indicator).
- The patient should not reduce their gluten intake prior to testing.
Diagnosis
- The gold standard diagnostic method is intestinal mucosal biopsy.
- Three samples are taken from the second or third portions of the duodenum.
- A biopsy will demonstrate the presence of intraepithelial lymphocytes, crypt hyperplasia, increased plasma cells and lymphocytes in the lamina propria, and potentially severe villous atrophy.
Treatment
- The cornerstone of treatment is a gluten-free diet.
- This diet involves eliminating all grains containing gluten, along with any derivatives. Specific foods to avoid or be mindful of include wheat, rye, barley, and hidden sources of gluten in various products.
- Close attention needs to be paid to hidden sources of gluten or hydrolyzed plant protein (HPP) not listing the source of the protein (wheat, corn, soy).
- Some specific examples of foods containing gluten include grains (wheat, barley, rye), pastes, glues, airborne flours, communion wafers, fat replacers, certain medications, and beverages like beer.
Oat Controversy
- Oats are generally considered safe but are often difficult to obtain if not contaminated with gluten.
- For newly diagnosed patients with celiac disease, oats should be avoided until remission on a gluten-free diet is achieved.
- Incorporating pure, uncontaminated oats into the diet can be done at a rate of up to 2 ounces per day.
Safe Foods
- Safe foods include plain meats, fish, and poultry.
- Other safe foods include fresh fruits and vegetables, plain frozen vegetables and juices, butter, vegetable oils, gravy, creams, white sauces with permitted flours, gelatin, homemade custard, meringue, gluten-free cakes (using approved ingredients), rice, corn, soy, millet, buckwheat, corn, and rice cereals.
- Other gluten-free options include sugar, jelly, jam, and honey.
Fiber
- Fiber intake should be increased to at least 25 g/d for women under 50 years of age and 38 g/d for men in the same age group; older adults (50+) should aim for 21 g/d intake for women and 30 for men.
- Fiber can be added through the intake of ground flax seeds in cereals, yogurt, and baked goods. Switching from white rice to brown rice and incorporating soups or main courses made from beans and legumes are effective ways to increase fiber intake.
Enrichment
- Gluten-free foods are often reformulated to include vitamins and minerals such as brown rice flour, quinoa, flax, and buckwheat.
Additional Considerations
- Celiac patients are advised to be vigilant regarding cross-contamination when sharing utensils or dining out, as well as shopping.
Food Intolerances and Allergies
- Some individuals with celiac disease may exhibit lactose intolerance.
- Lactose intolerance is often addressed by temporarily eliminating lactose from the diet for a month or more and then gradually introducing it back.
- Individuals can address lactose intolerance by selecting lactose-free milk products or using lactase enzyme supplements.
- Lactose-free alternatives include using dairy-free, gluten-free beverages like soy, almond, or rice milk.
- It is recommended that these drinks be enriched with calcium, vitamin D, and other nutritional supplements. Aged cheese and yogurt with active cultures are good alternatives for those looking for dairy sources.
- It also is helpful to take calcium and vitamin D supplements, and conduct a baseline DEXA scan to monitor osteoporosis, if needed.
Vitamin and Mineral Issues
- Those with CD may experience deficiencies in iron, folate, calcium, and vitamin D.
- Individuals should receive nutritional supplements of vitamins (A, E) and vitamin K.
- Individuals diagnosed with CD and experiencing osteomalacia (soft bones) or osteoporosis (reduced bone density) may need calcium and vitamin D supplements along with measures like daily exercise to prevent problems.
- Smoking and alcohol use should be avoided, and Hormone Replacement Therapy (HRT) may be considered for postmenopausal women.
Diarrhea/Constipation
- Symptoms of diarrhea often resolve within two weeks of starting a gluten-free diet.
- Temporary lactose-reduced/lactose-free diets and adequate hydration may be beneficial. Constipation can also be an issue, and increasing fiber and fluid intake can help in these cases.
Diabetes and Celiac Disease
- Patients with both celiac disease and diabetes mellitus (DM) may or may not experience symptoms of celiac disease, yet the condition poses a risk factor and should be evaluated by medical professionals.
- Routine screening for celiac disease is recommended for patients diagnosed with Type 1 DM. Dietary strategies like frequency monitoring of blood sugar, keeping a food diary, counting carbohydrates for meal planning, including healthy protein sources at each meal, including high-fiber gluten-free foods, and ensuring adequate amounts of calcium and vitamin D in the diet are key considerations. Additionally, incorporating iron-rich gluten-free foods is crucial.
Liquid Nutritional Supplements
- Liquid nutritional supplements such as Ensure, Boost, and Scandishake can promote weight gain for patients with severe malabsorption and weight loss.
- However, it's crucial to evaluate the potential presence of gluten in these supplements.
Treatment
- If symptoms persist despite adhering to a gluten-free diet, non-compliance may be the explanation.
- Secondary hyposplenism can be addressed with pneumococcal vaccination and medical evaluation for any underlying infections.
Follow Up
- Individuals should be monitored for the improvement of their symptoms, with a duration for healing varying by the specific challenge.
- A timeframe of 2 weeks is needed for the resolution of symptoms, while mucosal healing may take 3-6 months.
- IgA antibody and tissue transglutaminase antibody levels should drop to undetectable levels within 6 months, although IgG antigliadin may remain present for up to a year.
- Dermatitis herpetiformis may take 18 months for improvement, with medication discontinuation possible.
- Bone densitometry should be repeated every year to monitor possible osteoporosis or osteomalacia.
- Biopsies should be repeated every 5 years or as medically necessary.
Refractory Celiac Disease
- Refractory celiac disease is diagnosed when persistent symptoms of malabsorption persist despite a gluten-free diet for at least six months, with ongoing villous atrophy during a follow-up duodenal biopsy.
- Blood tests (antiendomysial and antigliadin) should be negative.
- Refractory celiac disease is more common among older adults.
- Patients with refractory celiac disease are at risk of developing or worsening related conditions like lymphoma or cryptic enteropathy associated T-cell lymphoma. Treatment (corticosteroids, immunosuppressive agents) may be necessary.
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Test your knowledge about celiac disease, its symptoms, diagnosis, and treatment options. Explore the facts about gluten and how it affects those with this condition. This quiz is a great way to learn about managing celiac disease effectively.
