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Celiac Disease and Gluten Intolerance

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Celiac Disease and Gluten Intolerance Powered By Docstoc
					Dr. Daljit Singh
Principal & Professor of Pediatrics
Dayanand Medical College & Hospital
Ludhiana, Punjab
                                      PHOTO



CURRENT APPROACH TO DIAGNOSIS AND
MANAGEMENT OF CELIAC DISEASE

19-1-2012     9 am
    CURRENT APPROACH TO
DIAGNOSIS AND MANAGEMENT OF
       CELIAC DISEASE




              Dr. Daljit Singh,
              Principal & Professor of Pediatrics
              Dayanand Medical College & Hospital
              Ludhiana
         About Celiac Disease
 Celiac disease is a state
  of heightened immune
  responsiveness to gluten
  (wheat, rye, barley
  proteins) in genetically
  susceptible people
  leading to autoimmune
  enteropathy often with
  systemic manifestations
                 NEJM, 2007
                      CD - History

Sir William K Dicke

                      • 1888 : Samuel Gee described illness

                      • 1950 : W Dicke identified gluten as cause

                      • 1954 : Paulley described biopsy changes

                      • 1970 : Genetic link was found

                      • 1997 : Role of TTG (Tissue Transglutaminase)
Celiac disease – India

                   Total population 12,573
                   Anti tTG tested   2,167 (38.5%)
                   Seroprevalence     1.44%




        Makharia G K, J Gastroenterol Hepatol, 2010
       Recent change

 Incidence

 Age at presentation

 Presenting features
            Clinical presentation
Classic CD
Diarrhea, vomiting, abdominal pain
abdominal distension, failure to thrive
weight loss, muscle wasting, malabsorption



   Indian data
   26% of all malabsorption
   16.6% of all chronic diarrhea
                                                               *Yachha SK et al IJG 1993
                                                 Mohindra S et al J Health Popul Nutr 2001

    (n=134)
    Short stature 60.4%
    Anemia 40.0% ( microcytic hypochromic 79.1%, dimorphic 20.9%)
    Serum transaminases raised in 38.8 %
                                             Rawal P, Thapa BR Iranian J Pediatrics 2010
                      Failure to thrive
                     Chronic diarrhea
                      Short stature
Pediatrician         Malabsorption
                      Irritability
                     Rec abdominal pain
                      Chr/rec diarrhea
Gastroenterologist   Anemia
                      Abdominal distension
                     Elevated transaminases
                      Anemia
Hematologist
                      Vitamin ulcers
                     Aphthousdeficiencies
Endocrinologist
                         IDDM,
Immunologist             Osteoporosis
Gynecologist
Dentist
                           Amenorrhea
Dermatologist         Seizures
                      Cerebellar ataxia
Neurologist
  Celiac disease shows Iceberg phenomenon

                                                             Manifest
       Symptomatic                                           mucosal lesion
      Celiac Disease




                             Silent Celiac
                                Disease



                       Latent Celiac Disease                  Normal
                                                              Mucosa


For every patient diagnosed, 3-10 remain undiagnosed
                                               Cronin CC et al. Am J Gatroenterol 2003
       Diagnosis of Celiac Disease
              Alberta Childrens’ Hospital, Canada




         266 children
         61% female
         Median age at Dx 8 yrs




_______Pre-screening_____           _________Screening________
Distribution after Introduction of Screening
                  Classic Celiac      GI Symptoms            Extra-intestinal      Silent

                 2000 - 2006
                  100%

                   90%

                   80%

                   70%
  Patients (%)




                   60%

                   50%

                   40%

                   30%

                   20%

                   10%

                    0%
                           < 3       3 - 9     10 - 17   .      Female      Male
                                 Age (years)

                          n = 30     n = 82    n = 87           n = 123   n = 86
Prevalence of CD among siblings (DMCH data)




                  Index cases (n=80), 74 siblings
                    63 screened with anti tTG
                                 I
Positive (15)             Borderline (3)        Negative (45)


Biopsy positive          Biopsy positive        Biopsy Positive
(13/15)                         (0)                    (1/3)

                      22% found to have CD                IJG ,2003
     Investigative Diagnosis
 Serology
      AGA              EMA    TTG

      1980             1990   2000

 Small bowel biopsy
       Antibodies




IgA tTG Less diagnostic in children under 5 years

IgA EMA More costly, time-consuming
        Poor sensitivity in small children
        Better screen in diabetes
                Serological tests
       All testing done while on gluten diet
    IgA tTGA is the first choice
    If tTGA test is equivocal, use IgA EMA test
    If serology is negative, check for IgA deficiency
    If IgA deficiency is confirmed, use IgG tTGA and/or IgG EMA


134 cases
 Mean serum anti tTG 164 U/ml (0-749 )
 15 patients negative for the serology but 8 had IgA deficiency,
  all had histopathology suggestive of celiac disease
                              Rawal P, Thapa BR Iranian J Pediatrics 2010
                                BIOPSY
    Six to eight biopsies from the second and third parts of the duodenum
    Need to be on gluten diet      ? Need for biopsy if tTGA >100 u
                                                                 Barker et al, 2005

  Marsh staging
 Stage 0 : Normal mucosa
 Stage 1 : Increased intraepithelial cells, lymphocyte infiltration of lamina propria
 Stage 2 : Crypt hyperplasia
 Stage 3 : Villous atrophy
 Stage 4 : Total mucosal atrophy
                 Suggestive clinical features of celiac disease

                                      Perform IgA tTG antibody test


            Positive                                                           Negative
        Small bowel biopsy                                            High clinical suspicion?
                                                              Yes                                         No
 Positive                 Negative                                                       Low probability of celiac
                                                       Small bowel biopsy                consider total IgA test
                       F/U                                                               to R/O IgA deficiency
Dx confirmed            consider other dx ,
                       consider repeat bx
                                                  Positive               Negative
                                                Tx and monitor
                                                                           Celiac ruled out,
                                                                           look for other cause
                                              Improvement?
                                          Yes                  No
                                                             Evaluate for possible secondary cause of symptoms
                                   Dx confirmed
CD - Treatment


   Only proven treatment for
   celiac disease is a
   gluten-free diet (GFD)


   Strict, lifelong diet restriction
   Avoid: Wheat, Rye, Barley ? Oats
      Celiac Disease - Management

Consultation with a skilled dietician for GFD
Education about the disease
Lifelong adherence to GFD
Identification & treatment of nutritional deficiencies
Access to an advocacy group
Continuous long term follow-up by a multidisciplinary team
                                             Cross Contact
                               wheat


“Gluten-free”                                           oats




       National Food Authority of US has two
       definitions
           Gluten-free refers to NO gluten
           < 200 ppm is low gluten

       Any amount of gluten may cause
       autoimmune response even if no
       symptoms

       Kupper, 2005
What not to eat
     Chappati, parontha
     Bread
     Dalia, suji, maida
     Biscuits
     Noodles
     Karha parshad
Eating out?

       Rolls, cakes, pastries
       Pasta, pizza
       Patties, samosa, gol gappe
       Burger, hot dog
Hidden sources of Gluten
  in prepared foodstuff
 Malt made from barley
  Malt syrup, malt extract, malt flavoring, malt vinegar
  Beer, whiskey

 Food additives
  Soy sauce, modified food starch
  Emulsifiers, vegetable protein

 Processed foods
  Sausage, gravies and sauces
                      Food labeling


 Food Allergen Labeling & Consumer Protection Act in USA

  Effective January 2006
      Food manufacturers must clearly label all products for:
       • Eggs          • Shellfish
       • Wheat         • Fish
       • Soy           • Peanuts, tree nuts


       INDIA?
Hidden Gluten in the Kitchen
  Sources of Gluten
aren’t always obvious
Lipstick / Gloss / Balms

Mouthwash / Toothpaste

Stamp and Envelope Glues

Herbal and Mineral preparations

Prescription or OTC Medications
Can eat…
Gluten Free Menu For India
          Nutrition
 Iron
 Calcium
 Vitamin D
 Vitamin B complex
 Dietary fiber
Dietary Adherence:
A Common Problem
       Only 50% with a chronic
        illness adhere to their
        treatment regimen
        including:
          diet
          exercise
          medication

       Dietary compliance can be
         the most difficult aspect of
         treatment
                     Follow-up
Serologic markers (serum IgA tTG) to monitor compliance with gluten-
  free diet. Antibody levels return to normal within 3 to 12 months

Repeat small bowel biopsy 3-4 months after initiation of gluten-free
  diet is not necessary if patient responds appropriately to therapy

If the patient does not respond as expected despite adherence to a
     gluten-free diet, consider diseases that may mimic celiac disease.
                The Future…
 Bioengineer wheat free of antigenic moieties
 Block DQ interaction with gluten ? Block TTg
 Block de-amidation
 Predigest peptide fragments with enzyme therapy
 Block zonulin effects on permeability ( correction
  of intestinal barrier defect)
 Immuno-modulatory strategies

				
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