celiac disease & non celiac gluten sensitivity chanda k. ho, md mph march 23, 2013
TRANSCRIPT
Celiac Disease & Non Celiac Gluten SensitivityChanda K. Ho, MD MPH
March 23, 2013
Objectives Gluten Free Diet Diagnosis and Management of Celiac
Disease Irritable Bowel Syndrome and Celiac
Disease Non-Celiac Gluten Sensitivity Recommendations
Wheat (Triticum spp) 1st cultivated approximately 10,000 years
ago in fertile crescent Relatively novel to man’s diet 2010 world production 651 million tons
3rd most-produced cereal after maize (844 million tons) & rice (672 million tons)
Major diet component b/c need to increase agricultural production
Wheat, Barley, Rye
Wheat Gluten- main structural
protein complex Primary proteins are
gliadin and glutenin. Gliadin contains bulk of
toxic complements- contains repeating patterns of AA that GI tract cannot break down
Gluten “The New Diet Villain” High profile celebrities New Diet Fad Public has adopted this
concept quite readily Google: PubMed
searches- 4,598: 1
Springen K. Newsweek. 2 Dec 2008
www.nytimes.com
Gluten Free Diet
15-30 million Americans are buying gluten free products
$2 billion of gluten free products sold in 1 year
Public awareness of non celiac gluten sensitivity in US has been shown to be higher than that of celiac disease
Di Sabatino et al. Ann Intern Med 2012
Gluten-Free Diet Foods containing wheat, rye, and barley OK to eat: soybean/tapioca flours, rice, corn,
buckwheat, potatoes Read labels on prepared foods/condiments, may
contain stabilizers/emulsifies that have gluten Wine is gluten free. Avoid beers, ales, lagers,
and malt vinegars. Dairy may be not well tolerated given secondary
lactose intolerance Limit oat consumption
Diagnosing Celiac Disease
Celiac Disease (CD): definition
Chronic immune-mediated disease in genetically susceptible individuals
Environmental precipitant- gliadin (toxic fraction of gluten protein)Found in wheat, rye, barley
Improvement with gluten withdrawal Clinical manifestations are variable
Classical CD
Symptoms of malabsorption such as steatorrhea, weight loss, or other signs of nutrient or vitamin deficiency [12].
The presence of characteristic histologic changes (including villous atrophy) on small intestinal biopsy.
Resolution of the mucosal lesions and symptoms upon withdrawal of gluten-containing foods, usually within a few weeks to months.
The Celiac Iceberg
SymptomaticCeliac Disease
Silent Celiac Disease
Latent Celiac Disease
Genetic susceptibility: - DQ2, DQ8 Positive serology
Manifest mucosal lesion
Normal Mucosa
Potential
Asymptomatic/
Non-classical CD
Definitions of Celiac Disease CLASSIC: malabsoprtion, fully developed villous
atrophy, GI symptoms ATYPICAL: no GI symptoms but evaluated for
IDA, anemia, short stature, osteoporosis, etc SILENT: no symptoms, no
features/complications, found incidentally LATENT: CD pts who responded to have a GRD
and have normal histology OR pts with normal histology now on GFD who go on to develop CD (normal mucosa, +Ab test)
AGA Technical Review, Gastro, 2006.
Who Should Be Tested?
GI symptoms including chronic/recurrent diarrhea, malabsoption, distension, bloating
Symptoms suggestive of IBS and/or Lactose Intolerance
Patients with Type 1 DM, Autoimmune disorders, 1st/2nd degree relatives of individuals with CD, Down, Turner, or Williams syndromes
Who Should Be Tested? Iron Deficiency Anemia Folate/B12 deficiency Persistent elevation in AST/ALT Short Stature Delayed puberty Recurrent migraines Recurrent fetal loss Low Birthweight Infants
Serologic TestingSerologic Test
Sensitivity %
Specificity %
Features
IgA AGA 85-90 90 ELISAFalse positive with mucosal damageReplaced by other markers
IgA EMA 97.4 99.6 Immunofluorescence with human umbilical cord or monkey esophagusSubjective, time consuming, expensive
IgA TTG 95.1 98.3 ELISA, human recombinant or RBC-derivedNonsubjective, less expensiveLoss of specificity with autoimmunity
IgA DGP 95 97 ELISAPositive in 80% of cases w/ IgA defDeamidated gliadin peptides
Rostom et al. Gastroenterol 2006
Guidelines for Diagnosis of Celiac Disease Typical symptoms of CD Positivity of serum CD IgA class autoantibodies
at high titer HLA-DQ2 and/or HLA DQ8 genotypes Celiac enteropathy found on small bowel biopsy
Crypt hyperplasiaVillous atrophy Intraepithelial lymphocytosis
Response to a GFDESPGHAN Guidelines for Diabnosis of
Celiac Disease
Monitoring Response to GFD 70% with noticeable clinical improvement within 2
weeks. Symptoms > Histology Patients should be evaluated 4-6 weeks after
starting GFD Use of serologic testing to monitor response
Normal levels do not necessarily mean histologic recovery Levels which do not fall, however, indicate ongoing gluten
ingestion (intentional or inadvertent) Requires pre-treatment elevated levels to be clinically useful
Genetic Testing for Celiac Sprue
Human leukocyte antigen (HLA) alleles associated with celiac disease
Sensitive but NOT specific 30% Caucasians carry DQ2 or DQ8 A negative test excludes celiac disease
with 99% confidence
Schuppan D. Gastroenterology. 2000: 119: 234-242
Kaukinen, K, e al. Am J Gastroenterol. 2002: 97: 695-699
?Repeating Small Bowel Biopsies If nonresponder to GFD Confirm mucosal healing
Nonresponders Patients with poor compliance or
inadvertent ingestion of gluten May have histologic features that overlap
with CD but due to another undiagnosed disorder
Concurrent IBS, lactose intolerance, SIBO, pancreatic insufficiency, microscopic colitis
Refractory sprue Ulcerative jejunitis or intestinal lymphoma
Other factors to consider in CD management Nutritional Deficiencies: iron, folic acid,
calcium, Vit D Constipation (GFD are low in fiber)- Rx
with psyllium Prevention of bone loss evaluate with
DEXA scan Pneumovax Dermatitis herpetiformis
IBS and Celiac
Rome III Criteria for IBS
Recurrent abdominal pain or discomfort, at least 3 days/month in the last 3 months associated with 2 or more of the following Improvement with defecationOnset associated with a change in frequency
of stoolOnset associated with a change in form of
stool
Longstreth et al, Gastroenterology 2006: 130: 1480-1491.
IBS and diet Individuals with IBS complain of subjective food
intolerance twice as much as controls Up to 25% of general US pop believe they have
a food allergy True FA 4-8% children, 1-4% adults 50-90% presumed food allergies are food intolerance
or aversion (non-immune mediated)
Eswaran et al Gastro Clin N Am 2011
IBS and Celiac Disease
Event IBS patients % Gen Pop %
Colitis/IBD 0.51-0.98 0.3-1.2
CRC 0-0.51 0-6 (age dep)
Thyroid dysfxn 4.2 5-9
Celiac sprue 3.6 0.7
Lactose intol 38 26
Cash et al. Am J Gastroenterol 2002; 97:2812.
Date of download: 8/6/2012Copyright © 2012 American Medical Association.
All rights reserved.
From: Yield of Diagnostic Tests for Celiac Disease in Individuals With Symptoms Suggestive of Irritable Bowel Syndrome: Systematic Review and Meta-analysis
Arch Intern Med. 2009;169(7):651-658. doi:10.1001/archinternmed.2009.22
Screening for Celiac Disease
Routine serologic screening for celiac sprue should be pursued in patients with diarrhea predominant IBS and mixed IBS (Grade 1B recommendation)
ACG Functional Bowel Disorders Task Force 2009
What is Non-Celiac Gluten Sensitivity?
Definitions
Encompasses a collection of medical conditions where gluten has an adverse effect
Can be clinically indistinguishable from celiac sprue but testing often negative or inconclusive
Improves with a gluten free diet
Murray et al. Am J Gastroenterol 2009
Gluten Sensitivity
Celiac DiseaseIBS
Verdu EF, et al. Am J Gastroenterol 2009: 104: 1587-94.
Non-Celiac Gluten Sensitivity
Cases of gluten reactions in which neither allergic nor autoimmune mechanisms can be identified.
Diagnosis by exclusion Prevalence of extraintestinal symptoms
such as behavioral changes, bone or joint pain, muscle cramps, leg numbness, weight loss and chronic fatigue
Non-Celiac Gluten Sensitivity Still not a well-defined clinical entity There are data to suggest improvement in
symptoms on a GFD in non-celiac patients
Di Sabatino, J Clin Gastoenterol 2013
Non-Celiac Gluten Sensitivity Abdominal pain 68% Eczema/rash 40% Headache 35% Foggy mind 34% Fatigue 33% Diarrhea 33% Depression 22% Joint pain 11%
Non-Celiac Gluten Sensitivity
Only recently has this been formerly studied
Strongest evidence of this entity- DBRC trial of FODMAP-depleted gluten in 34 patients who had celiac dz excluded..
Gibson et al. Am J Gastroenterol 2012: 657-665
Effect of Gluten on Symptoms in IBS Patients
Biesiekierski et al Am J Gastroenterol 2011;10:1038
Effect of Gluten on Pain/Bloating in IBS patients
Biesiekierski et al Am J Gastroenterol 2011;10:1038
Effect of Gluten on Fatigue on IBS patients
Biesiekierski et al Am J Gastroenterol 2011;10:1038
Proposed Management for Patients with IBS-like symptoms and minimal histologySymptom LD HLA Serology Treatment
IBS + + + GFD
IBS + Consider other cause
IBS - + + Consider GFD
IBS - - - Tx IBS
Eswaran et al Gastro Clin N Am 2011
Verdu Am J Gastro 2009
FODMAP diet in the management of Functional GI symptoms Fermentable Oligo-di and Mono
Saccharides and Polyols Induce luminal distension, food chemicals
that stimulate the Enteric Nervous System and gluten may trigger symptoms in non-celiacs via an unknown mechanism
Fermentable readily by bacteria, slowly or poorly absorbed by small intestine
FODMAPS
Fruits with fructose > glucose Fructan containing vegetables Wheat based products Sorbitol and lactose containing foods Raffinose containing foods Increasingly being recommended to
manage patients with functional GI symptoms
Remaining questions
Is this just potential celiac disease? Do patients without evidence of celiac
disease who are interested in GFD need to be on a strictly GFD or just decrease gluten?
Are other components of wheat causing symptoms?
Nocebo effect?
Conclusions Non-celiac gluten sensitivity currently
encompasses a broad array of disorders ranging from potential CD to food hypersensitivity to IBS with identified food trigger.
Several proposed mechanisms but pathogenesis is not clearly understood.
Non-celiac gluten sensitivity needs to be better defined and an optimal diagnostic algorithm is needed.
Larger double-blind RCT studies are needed. Gluten free diet may be reasonable to try in
motivated patients.
Celiac Disease Management Recommendations Consultation with a skilled dietician Education about the disease Lifelong adherence to a GFD Identification and treatment of nutritional
deficiencies Access to an advocacy group Continuous long-term follow-up by a
multidisciplinary team
Thank you!