Here’s a link to a well-described case report. Her Searing Gut Pain Suggested Celiac Disease. Why Didn’t Cutting Out Gluten Help?
This 57 year old with ‘presumptive’ celiac disease did not improve with a gluten-free diet. After an initial self-diagnosis and subsequently an endoscopy that also suggested celiac disease, she did not improve. While the doctors involved in her care had labeled her ‘noncompliant,’ it turns out she did NOT have celiac disease and improved after the right diagnosis (diagnosis noted at bottom of this post).
My take: There are several entities that can mimic celiac disease (even histologically), including Crohn’s disease, Autoimmune enteropathy, CTLA4 deficiency, and Whipple’s disease (the diagnosis in this case). When someone is not getting better, the diagnosis needs to be reconsidered.
In a recent study (C Canova et al. J Pediatr 2018; 198: 117-20) from Padua, Italy compared 1233 individuals with celiac disease to a comparison group of 6167 (from a population-based cohort of >200,000 individuals). In this longitudinal study with a maximum followup, the authors found no increase risk of fractures in youths diagnosed with celiac disease (HR of 0.87).
- 22 individuals had fractures compared to 128 in the reference population
- Median age of celiac diagnosis was 6 years
- While celiac disease is linked to osteoporosis, “the vast majority of individuals with childhood celiac disease are likely to heal shortly after the introduction of a gluten-free diet.”
My take: Institution of a gluten-free diet for children with celiac disease likely removes the risk of osteoporosis.
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- Good News for Celiac Disease –Gastroenterology 2010; 139: 763. Mortality NOT worsened in undiagnosed celiac disease (identified by review of serology) in Olmstead County, though bone density decreased. n=129 of 16,847. (?milder cases undiagnosed)
- Common to be ‘D-ficient
Amelia Island -Restaurant Greeting
Cumberland Island 2018
Briefly noted: P Singh et al. Clin Gastroenterol Hepatol 2018; 16: 823-36. After a systemic review which selected 96 articles from a pool of 3843 published between 1991 through 2016, the authors determined a pooled global prevalence of 1.4% in 275,818 individuals based on seroprevalence (positive TTG or EMA). Biopsy-confirmed celiac disease was noted in 0.7% in 138,792 individuals.
In their study, biopsy-proven disease was most prevalent in Argentina, Egypt, Hungary, Finland, Sweden, New Zealand, and India.
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DJ Gracie et al. Gastroenterol 2018; 154: 1635-46. This study of 405 adults indicated that IBD triggers anxiety and that anxiety triggers IBD. Specifically: “Baseline CD or UC disease activity were associated with an almost 6-fold increase in risk for a later abnormal anxiety score (hazard ratio [HR], 5.77; 95% CI, 1.89-17.7). In patients with quiescent IBD at baseline, baseline abnormal anxiety scores were associated with later need for glucocorticosteroid prescription or flare of IBD activity (HR 2.08; 95% CI, 1.31-3.30).”
RL Dalal, B Shen, DA Schwartz. Inflamm Bowel Dis 2018; 24: 989-96. This review provides updated information on epidemiology, diagnosis, and treatment recommendations for pouchitis.
A Alper et al. JPGN 2018; 66: 934-6. Key finding: Celiac disease is “not increased in children with IBD compared with non-IBD children with gastrointestinal symptoms.” False-positive tTG serology can occur.
AK Shaikhkhalil et al. JPGN 2018; 66: 909-14. The authors showed that using a quality-improvement effort, there was increase utilization of enteral exclusive therapy (EEN). Baseline 5.was <5% and by completion of intervention, utilization increased to approximately 50%. The interventions to achieve this are specified in this article, including talking points. EEN is described as “nutrition therapy.” Patients are offered oral EEN and if not adequate by 3-4 days, nasogastric feedings are initiated (~15%). Interestingly, of those to complete EEN therapy, 97% did not need NG placement.
Pictures from Ameilia Island:
Many patients receive a gluten-free diet (GFD) prior to a definitive diagnosis of celiac disease. The diagnostic yield of serology can significantly decrease within a month after institution of a GFD. A recent study (VK Sarna et al. Gastroenterol 2018; 154:886-96) has identified an HLA-DQ-Gluten Tetra
mer Blood test which can accurately identify celiac disease despite the implementation of a GFD. This test quantifies HLA-DQ-gluten tetramer binding to T cells with flow cytometry. Key findings:
- For patients receiving a GFD, the sensitivity was 97% and the specificity was 95% for the diagnosis of celiac disease
- For patients not receiving a GFD, the sensitivity was 100% and the specificity was 90% for the diagnosis of celiac disease
My take: An accurate test to determine if celiac disease is present for those who have started a GFD would be quite helpful. This HLA-DQ-Gluten Tetramer blood test still needs further validation in more patient populations. This test is NOT commerically-available at this time.
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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
Chattahoochee river -Morgan Falls
Using data from the prospective TEDDY (The Environmental Determinants for Diabetes in the Young) from 2004-2010, a recent study (S Koletzko et al. JPGN 2018; 66: 417-24) has shown that cesarean section is not associated with an increased risk of celiac disease (CD) or celiac disease autoimmunity (CDA). TEDDY participants are at increased risk for CD and type 1 diabetes (T1D) based on HLA-risk genotypes.
- Of the 6087 singletons, 1600 (26%) were born via C-section
- C-section was associated with a lower risk for CDA (HR 0.85) and a lower risk of CD (HR 0.75)
My take: While environmental factors are likely to be responsible for increasing incidence of CD, C-section compared to vaginal delivery does not appear to be a risk factor.
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Amber Cove, Dominican Republic
A recent double-blind, randomized, placebo-controlled trial (E Lionetti et al. J Pediatr 2018; 194: 116-22) examined the effect of adding oats to the diets of 79 children and compared this to a control group of 98 children; all participants had biopsy-proven celiac disease (CD).
- “A large body of evidence has so far suggested that the consumption of pure oats is safe in the vast majority of patients with celiac disease.”
- Still concerns persist. In addition, the purity of oats cannot always be guaranteed.
- Previous studies were limited by small sample sizes, short follow-up, limited details regarding oat used, and lack of detail about cross-contamination.
This study sought to remedy prior trial deficiencies and examined clinical indices, serology, and intestinal permeability after 6, 9 and 15 months.
- There were no statistically significant clinical, serologic, or intestinal permeability variables when comparing the oat group to the control group.
My take: Oats, free of cross contaminants, are safe to incorporate into a gluten-free diet for CD.
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.