Gluten Intolerance

Question 1

Non-GI presentations of Celiacs

Answer 1

Unexplained iron deficiency anemia
Folic acid or vit B12 deficiency
Reduced serum albumin
Unexplained elevated LFTs
Other autoimmune disorders 
Down syndrome or Turner syndrome
Selective IgA deficiency

Question 2

What percentage of those with Dermatitis herpetiformis will have CD?

Answer 2

85%

Question 3

What is the most common non-GI presentation of CD?

Answer 3

Osteopenia/Osteoporosis

*All newly diagnosed CD should have a bone density scan

Question 4

What are some neurologic symptoms of CD from fat an vitamin malabsorption?

Answer 4

Ataxia (B12) 
Night blindness (vitamin A) 
Seizures
Headaches
Epilepsy
Mood disturbances
Peripheral neuropathies

Question 5

What are some gynecologic and fertility problems associated with CD?

Answer 5

Amenorrhea
Infertility 
Spontaneous abortions
Intrauterine fetal growth retardation
Male infertility reported

Question 6

How is a diagnosis of CD made??

Answer 6

IgA endomysial antibody (EMA)
IgA tissue transglutaminase (tTG)
IgA and IgG deamidated Gliadin antibodies
**Anti gliadin antibodies of little value

Question 7

What is seen on small intestine biopsy of someone with CD?

Answer 7

Scalloping or notching of the small bowel folds
Multiple biopsies should be obtained (6-8)
Small intestinal villous atrophy, intraepithelial lymphocytosis and crypt hyperplasia

Question 8

What are two reasons you may get false negatives with testing for CD?

Answer 8

Antibody levels fall on a gluten free diet (takes about 6-8 weeks)
Celiac patients that have IgA deficiency – might make IgA tTG and EMA falsely negative; IgG Abs useful in this case

Question 9

What are some other things that might cause villous atrophy?

Answer 9

NSAIDs
Infections
IBD

Question 10

What HLA do people with CD have?

Answer 10

95% have HLA DQ2

5% have HLA DQ8

Question 11

Would you use HLA to diagnose CD?

Answer 11

NO!

About 40% of people with european ancestry are DQ2 or DQ8 – but may be useful in ruling out celiacs

Question 12

What is the treatment for CD?

Answer 12

Gluten free diet – avoiding anything with wheat, rye and barley gluten; avoid malt

Question 13

Should asymptomatic people with CD be treated?

Answer 13

Yes - there is a 4 fold increase in mortality (CVD and malignancy) which is likely normalized with GFD

Question 14

What are some malignant complications of CD?

Answer 14

Enteropathy associated T-cell lymphoma – high-grade T cell NHL; 5 year survival rate ~10%; occurs 20x more frequently in patients with CD
*risk of this normalizes on GFD

Question 15

What is a wheat allergy?

Answer 15

Classic food allergy that affects skin, GI track and/or respiratory tract
IgE mediated disease

Question 16

How do you diagnose wheat allergy?

Answer 16

Allergy pin prick testing

Question 17

What is non-celiac gluten sensitivity?

Answer 17

Patients who claim they feel better on a gluten free diet – no evidence of CD

Question 18

Why might people feel better on a GFD?

Answer 18

Fermentable fractions may cause symptoms

Major change in dietary intake – lower carb, more fruits and veggies

Question 19

Is there a downside to eating a GFD?

Answer 19

not really – may need a multivitamin

and watch for constipation if fiber is low in diet

Question 20

What is tropical sprue?

Answer 20

Environmental enteropathy – stunted growth and diarrhea that is common in developing countries
Malnutrition but supplementary feeding and vitamin supplementation are able to reverse the syndrome
Repeated bouts of diarrhea within the first 2 or 3 years of life – no single infectious agent identified
Histologically similar to celiac disease

Question 21

What iron salts are best absorbed??

Answer 21

Ferrous gluconate, ferrous sulfate