Download - Celiac Disease Kandeel
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Celiac Disease in women
Mohamed Kandeel, M.D.
Professor of Obstetrics and Gynecology
Menofyia University
Egypt
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Learning Objectives
At the end of this presentation you should:
1-Enumerate the problems a woman affected with celiac disease
may encounter during her life
2-Be aware of the methods of diagnosis of celiac disease
3-Describe effective control for the disease to minimize
symptoms and long term sequelae of the disease
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Magnitude of the Problem of Celiac Disease
Celiac disease is an autoimmune disease affecting the small
intestine. Various studies have shown its association with
other autoimmune endocrinologic disorders affecting different
organs -systems- of the body such as diabetes, thyroiddisorders and infertility. In fact 50% of patients affected with
celiac disease have atypical presentations not involving the
GIT and consequently, many celiacs are expected to seeks
medical advice from specialists other than gastroenterologists.
We, as Ob/Gyns, should be aware of the different
presentations of the disease that we may encounter at the
office.
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Definition
Celiac disease is a life long autoimmune enteropathy affecting
small intestine characterized by a permanent intolerance to
dietary gluten. Gluten is a protein found in the cereal grains of
wheat, rye, barley & oats.
In affected individuals, ingested gluten causes inflammation
and damage to the small bowel. This damage impairs thenormal absorption of food leading to nutritional deficiencies
and therefore, can affect the body in many different ways.
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Incidence
The incidence of Celiac disease varies between 1-100 to 1-300
in the general population according to geographical
distribution. Generally speaking, celiac disease is more
common in women than men. This high incidence can beexplained by the fact that women are more keen about their
health compared to males and therefore, they seek early
medical advise. The high incidence of the disease in women
can be just a simple reflection of this behavior.
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Incidence (Cont.)
The incidence of celiac disease varies among specific groups.
It ranges between 4-8% among women diagnosed with
unexplained infertility. About 6% of anemic women have
undiagnosed celiac disease. A recent study suggested that 3-4% of women who have osteoporosis have celiac disease.
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Effect on Menstruation
1- Amenorrhea is a possibility
2-Short fertile period: affected women have late menarche and
early menopause
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Effect on pregnancy and lactation
1-Iron deficiency anemia: due to
a-Malabsorption of dietary iron
b-Occult blood loss from gastro-intestinal tract
2-Poor absorption of folic acid leading to recurrent miscarriages
and increased theoretical risk of of neural tube defects in
babies of affected mother
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Effect on pregnancy and lactation
3-Increased incidence of IUGR and low birth weight babies
4-Higher incidence of preterm birth and Cesarean sections among
affected mothers
5-Shorter duration of breast feeding
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Effect on Fertility
1- Unexplained infertility
2-Recurrent miscarriages
3-Poor quality seminal fluid was detected in males affected with
celiac disease
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Effect on bone mineral density
Celiac disease decreases bone mineral density in affected
women. The underlying mechanism is related to calcium
malabsorption and subsequent increase in parathormone
secretion by the parathyroid which, in turn, increases boneturnover.
Treatment with vitamin D may be required in the presence of
osteomalacia.
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Complications
1-Malignancies: lymphoma of the small intestine, non Hodgkins
lymphoma, Cancer of the pharynx, oesophagus and small
intestine are all well recognized in association with celiac
disease.
2-Osteoporosis
3- Bleeding tendency
4-Refractory celiac disease: in longstanding cases not on; or notresponding to, free gluten diet
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Diagnosis
I- Symptoms include:
50% of patients show the classic form of the disease of chronic
diarrhoea, nausea, vomiting, flatulence, bloating, abdominal
pain and weight loss. Fatigue, weakness and lethargy are also
common associated symptoms.
Many affected adults lack GI symptoms & present with a wide
spectrum of manifestations such as insulin-dependent diabetes,
joint pains, osteoporosis, iron, folate, B12 deficiency,
depression, dermatitis herpetiformis & infertility
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Diagnosis (Cont.)
II-Serology: tests are used to measure antibodies formed againstthe breakdown products of ingested glutens and the enzymes
that mediate the tissue damage in the disease. Because of their
high sensitivity, they are used for screening. They also can be
used to monitor response of patients on strict gluen diet.
1-Antigliadin antibodies (AGA)
2-Anti-tissue antibodies (tTGA)
3-Antiendomysial antibodies (EMA)
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Diagnosis (Cont.)
III-The gold standard diagnostic test is endoscopic biopsy of the
upper small bowel. Because of the invasive nature of this, it
should be reserved only for those with positive screening
serology tests. However, A negative test may still prompt abiopsy if the clinical suspicion is high. 4-8 biopsies should be
obtained for diagnosis from either the distal duodenum or the
proximal jejunum.
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Diagnosis (Cont.)
IV-Prothrombin time and partial thromboplastin time: useful to
identify deficiency of vitamin K, which predisposes patients to
hemorrhage
V-Radiology: has no role in the diagnosis of celiac disease.
However, it can help rule out other pathologies of gastro-
intestinal disease.
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Treatment
1-The standard treatment is gluten free diet for life. It is essential
to relieve symptoms and avoid long term complications of the
disease. Avoid all foods made from wheat, rye, and barley.
Examples are:
-Breads, cereals, pasta, cakes and cookies
-Sausages, processed and canned meats-Yogurt, ketchup and mustard
-Candy bars and ice cream
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