Celiac Disease in Primary Care - PowerPoint PPT Presentation

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Celiac Disease in Primary Care

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Be suspicious of refractory IBS-D especially with associated celiac symptoms! ... & Babies Iron deficiency anemia: Unexplained or iron-therapy-refractory (2.3%-5.0%) ... – PowerPoint PPT presentation

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Title: Celiac Disease in Primary Care


1
Celiac Disease in Primary Care
  • Dustin M Adkins
  • Spring 2007

2
Essentials of Celiac Disease
  • Autoimmune disorder triggered by gluten
  • Gluten is a collective term for the storage
    proteins of wheat, rye, and barley.
  • Adaptive/innate immune response damages villi in
    the proximal small intestine
  • Not just GI complaints! A multisystem disorder
    with highly variable presentation
  • Increased risk of Non Hodgkins Lymphoma
    (2.7-6.3x) and overall mortality (1.9-3.4x)

3
Epidemiology
  • Not as rare as once thought
  • Affects 1100 in USA (AGA 2007)
  • Under-diagnosed

4
Classical (Textbook) Celiac Disease
  • Symptoms and complications of malabsorption
  • Hallmark Diarrhea/steatorrhea (chronic)
  • Abdominal distension, edema, extreme lethargy,
    weight loss, failure to thrive
  • Onset at any age, gradual or rapid
  • Often fulfills criteria for IBS. Be suspicious
    of refractory IBS-D especially with associated
    celiac symptoms!

http//www.pigur.co.il/imgceliac/celiac.jpg
5
Dermatitis Herpetiformis is classically
associated with Celiac Disease. Only in a
minority of patients.
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ents/Medicine/Gastroenterology/images/DHimage.jpg
http//pathmicro.med.sc.edu/ghaffar/mhcderm.jpg
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9.gif
6
Atypical Celiac Disease
  • MOST COMMON presentation
  • Extra-intestinal manifestations dominate
  • Blood, Bones, Babies
  • Iron deficiency anemia Unexplained or
    iron-therapy-refractory (2.3-5.0)
  • Osteoporosis Premature onset (1.0-3.4)
  • Infertility Unexplained, recurrent fetal loss
    (2.1-4.1)
  • Many other S/Sx short stature, fatigue, delayed
    puberty, vitamin deficiencies

7
Clinical Presentation of Celiac Disease
Summary of the clinical presentation of celiac
disease. Included 170 biopsy-diagnosed celiac
disease patients diagnosed between 1993 and 2000
(Lo 2003).
8
Asymptomatic Celiac Disease
  • Often detected when screening 1 relatives, or
    incidentally during EGD
  • Risk of complications, lymphoma, mortality still
    exists!

9
Associated Disorders (HLA DQ2/DQ8)
  • Autoimmune (10-fold ?)
  • Thyroiditis (3)
  • Type I Diabetes (1-12)
  • Sjögrens syndrome
  • Addisons disease
  • Autoimmune liver disease
  • Cardiomyopathy
  • Other related disorders
  • Down syndrome (3-12)
  • Turners syndrome
  • Williams syndrome
  • Ulcerative colitis
  • Crohns disease
  • IgA nephropathy
  • Occipital calcifications
  • Neuropsychiatric d/os

10
Diagnosis
  • Anti-tTG IgA is the single most effective test
    for PCPs! (95 Sens 98 Spec)
  • Genetic tests can only rule out Celiac disease
    (HLA DQ2/DQ8)
  • Duodenal biopsy (EGD) remains the Gold Standard

http//www.glutenfreeworks.com/gluten_explained.ph
p
http//www.bidmc.harvard.edu/display.asp?node_id7
715
11
Treatment Lifelong Gluten-Free Diet
  • Difficult task for the patient.
  • Should see a registered dietician
  • Complicated by fast-food lifestyles, hidden
    ingredients, poor labeling, and
    costly/unavailable specialty foods.
  • Lifelong diet normalizes mortality/comborbidity
    risks

Never advise a patient to start a Gluten-Free
Diet before biopsy! It alters the
histopathology requiring additional testing
(), and ticks off the
gastroenterologist!
12
Lifelong care for the Celiac Patient
  • Take a good history! Symptom improvement doesnt
    mean all gluten has been removed from the diet.
  • Make sure the patient has support
  • Celiac support groups
  • Tons of online info on gluten-free dieting
  • Work with pharmacist to avoid gluten in drugs
  • Nardil, Humira, Flonase, Claritinlook it up!
  • Inactive ingredients (dextri-maltose, dusting
    powder, starches)
  • Watch out for anemia, osteoporosis, infertility,
    and vitamin deficiencies

13
Participation time! Which is gluten-free?
Modified Food Starch
Malt
Wheat
Restaurant Contamination?
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