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Celiac Disease in Primary Care. Dustin M Adkins Spring 2007. 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

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Celiac disease in primary care l.jpg

Celiac Disease in Primary Care

Dustin M Adkins

Spring 2007


Essentials of celiac disease l.jpg
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 1:100 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.

http://webedit.caregroup.org/content/bidmc/Departments/Medicine/Gastroenterology/images/DHimage.jpg

http://pathmicro.med.sc.edu/ghaffar/mhcderm.jpg

http://merck.micromedex.com/images/bpm/BPM01DE05F09.gif


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Atypical Celiac Disease with Celiac Disease. Only in a minority of patients.

  • 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 with Celiac Disease. Only in a minority of patients.

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 with Celiac Disease. Only in a minority of patients.

  • Often detected when screening 1° relatives, or incidentally during EGD

  • Risk of complications, lymphoma, mortality still exists!


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Autoimmune (10-fold with Celiac Disease. Only in a minority of patients.↑)

Thyroiditis (3%)

Type I Diabetes (1-12%)

Sjögren’s syndrome

Addison’s 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/o’s

Associated Disorders (HLA DQ2/DQ8)


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Diagnosis with Celiac Disease. Only in a minority of patients.

  • 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.php

http://www.bidmc.harvard.edu/display.asp?node_id=7715


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Difficult task for the patient. with Celiac Disease. Only in a minority of patients.

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

Treatment: Lifelong Gluten-Free Diet

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 with Celiac Disease. Only in a minority of patients.

  • Take a good history! Symptom improvement doesn’t 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, Claritin…look it up!

    • Inactive ingredients (dextri-maltose, dusting powder, starches)

  • Watch out for anemia, osteoporosis, infertility, and vitamin deficiencies


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Participation time! with Celiac Disease. Only in a minority of patients.Which is gluten-free?

Modified Food Starch

Malt

Wheat

Restaurant Contamination?