Confirm Celiac Diagnosis by Biopsy Before Advising Gluten-Free Diet

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An intestinal biopsy is almost always necessary to confirm celiac disease

and is a must before committing a patient to the only effective treatment –

a lifelong gluten-free diet.

Sticking to such a restricted diet is difficult and expensive, Dr. Sheila

Crowe said at the annual meeting of the American College of Physicians. " A

lifelong gluten-free diet sounds simple, unless you’re the patient. ...

Eating out is very difficult, especially for children and teens who face a

lot of peer pressure. And eating gluten free at home is expensive. Studies

in the United States, Canada, and the United Kingdom confirm that a lifelong

diet of gluten-free foods costs about three times more than a normal diet, "

said Dr. Crowe, professor in the division of gastroenterology and hepatology

at the University of Virginia, Charlottesville.

Because treating celiac disease requires this lifelong commitment, a

positive serologic test isn’t enough to rule it in, she said. Nor are any of

the available immunologic tests, including the most widely used – tissue

transglutaminase IgA (tTG IgA) – specific enough to replace intestinal

biopsy as the sole method for reliably diagnosing celiac disease. " A

positive tTG test is not enough to place a person on this lifelong treatment

without confirmation from an intestinal biopsy, " she said. " This is

especially important for children, because of the higher likelihood of false

positives in that group. "

tTG IgA has a very high sensitivity and specificity, but it isn’t perfect,

Dr. Crowe said. " If you have a patient with clinical symptoms and the tTG

comes back negative, there is still a 10% chance that’s a false negative.

Another scenario could be a patient who has an autoimmune disease or a

relative with celiac, and is experiencing celiac symptoms. If the tTG came

back negative on that person, I would still do an endoscopy. "

The only possible exception might be a patient with celiac symptoms who

already has biopsy-proven dermatitis herpetiformis, with the classic

immunofluorescent deposits at the dermal-epidermal junction. " If you biopsy

these patients, the intestine will show the changes associated with celiac

disease every time, " Dr. Crowe said.

Celiac disease is no longer considered a disorder of childhood. " The disease

is there lifelong. It appears you cannot suppress the immune response, " she

said.

The intestine rapidly responds to a gluten-free diet, " But the tendency to

have an immunologic response to gluten is always there, " Dr. Crowe said.

Relapses are common. Patients are most likely to " fall off " the diet when

symptoms begin to abate, she said. They may simply feel " cured " and resume

old eating patterns, or they may drop the diet because of changes that can

occur as the intestine heals. " If a patient had diarrhea and malabsorption

of nutrients, they might find themselves getting constipated and gaining

weight on the gluten-free diet, fall off, and get ill again. Even if the

intestine is healed, the vast majority of data tell us that patient will

relapse, " at some point after abandoning the dietary restriction, Dr. Crowe

said.

This can lead to the development of refractory celiac disease, in which the

intestine fails to recover despite a gluten-free diet. Patients with

refractory celiac disease may be unable to fully absorb nutrients and need

supplemental feeding methods.

The goal of celiac management is to promote intestinal healing, optimize

nutrition, and avoid long-term damage, Dr. Crowe said. " It’s key to bring in

a knowledgeable dietitian to help. And I mean knowledgeable – not someone

who is going to hand your patient a diet sheet and that’s all. "

Many celiac patients are already nutritionally compromised at the time of

diagnosis. " This is the time to measure their nutritional parameters, " Dr.

Crowe said. " They may need supplements. Many are deficient in vitamin D,

iron, folate, zinc, or other trace elements. "

The risks of untreated disease " are not inconsequential. " Patients can

develop problems related to nutrient malabsorption, including osteopenia,

infertility, miscarriage, and intrauterine growth restriction, and are four

times more likely than the general population to develop a malignancy.

Guidelines for managing nutritional status exist, but there are no

evidence-based treatment guidelines for celiac disease, Dr. Crowe said.

" Aside from nutrition, you have to just advise them to follow good health

practices. I have several patients who still smoke, and yet they’re morose

about their gluten-free diet. I say, ‘Why are you worried about that? You

need to worry about quitting smoking!’ "

Dr. Crowe reported that she receives royalties from a book written for

patients with celiac disease.

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Ortiz, MS, RD

*The FRUGAL Dietitian* <http://www.thefrugaldietitian.com>

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