Celiac Disease in Primary Care

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Celiac Disease in Primary Care

• Dustin M Adkins
• Spring 2007

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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)

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Epidemiology

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

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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
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Dermatitis Herpetiformis is classically
associated with Celiac Disease. Only in a
minority of patients.
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ents/Medicine/Gastroenterology/images/DHimage.jpg
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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

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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).
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Asymptomatic Celiac Disease

• Often detected when screening 1 relatives, or
  incidentally during EGD
• Risk of complications, lymphoma, mortality still
  exists!

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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

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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

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p
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715
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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!
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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

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