55 WORLD GASTROENTEROLOGY NEWS JULY 2016 Editorial | Expert Point of View | Gastro 2016: EGHS-WGO | WDHD News | WGO & WGOF News | WGO Global Guidelines | Calendar of Events SYMPTOMS CD may present at any time in life with an ample spectrum of symptoms and signs. (Table 1) Classical CD presents with signs and symptoms of malabsorption, including diarrhea, steatorrhea, and weight loss or growth failure in children. In the so called non-classical form of CD, patients may present with mild gastrointestinal symptoms without clear signs of malabsorption or with extra-intestinal manifesta-tions. In this case the patient will suffer from abdominal distension and pain and a myriad of extraintestinal manifestations such as: iron-deficiency anemia, chronic fatigue, chronic migraine, peripheral neuropathy unexplained chronic hypertransami-nasemia, reduced bone mass and bone fractures, and vitamin deficiency (folic acid and B12), late menarche/early menopause and unexplained infertil-ity, dental enamel defects, depression and anxiety, dermatitis herpetiformis, etc. The family screening that follows a CD diagnosis has shown that CD may run asymptomatic, in asymptom-atic CD patients, however, the GFD will also improve the quality of life and health. DIAGNOSIS The gold standard for CD diagnosis relies on the presence in serum of CD specific serology and the intestinal biopsy shows the presence of increased number of intra-epithelial lympho-cytes (IELS) and various degrees of villous shortening. The CD serology encompasses serological markers targeting the auto-antigen, such as antiendomysial (EMA) and anti-tissue transglutamin-ase (anti-tTG), and those targeting the offending agent, against synthetic deamidated gliadin peptides (anti- DGPs). All of these antibodies are based on immunoglobulin A (IgA) or immunoglobulin G (IgG). Specifi- Table 1 The celiac disease clinical presentation may be monosymptomatic or oligosymptomatic, or with low intensity. The following signs or symptoms may be present at any age. Gastrointestinal symptoms (diarrhea, abdominal distension and/or pain, chronic constipation in children, dyspepsia, early satiety, and loss of appetite) Iron deficiency and anemia Chronic fatigue and lack of energy Chronic migraine Dermatological manifestations (such as rash, psoriasis, and blisters) Peripheral neuropathy – numbness and parasthesias Unexplained chronic hypertransaminasemia Vitamin deficiency ( folic acid, vitamin D, vitamin B12) Reduced bone density Unexplained infertility Delayed puberty, late menarche/early menopause Unexplained miscarriage, premature birth, or small for gestational age infant Incidentally recognized at endoscopy performed for GERD Dental enamel defects Depression and anxiety, moodiness and irritability Celiac crisis (cholera-like syndrome) Cascade with resource-sensitive options for the diagnosis of celiac disease. Resource level Cascade of diagnostic options Gold standard Medical history and physical examination Celiac disease–specific antibodies assessment and intestinal biopsy • Anti-tTG IgA and anti-DGP IgG. Total IgA to exclude IgA deficiency. Intestinal (duodenal) biopsies are always recommended • In certain situations biopsies may be omitted after discussing the pros and cons with an expert physician with special knowledge in celiac disease. Medium resources Medical history and physical examination Antibody assessment as a single diagnostic tool – when endoscopy is not possible or trained pathologists are not available; titer levels should be considered. Intestinal biopsies as a single tool* – in settings in which pathology is (perhaps remotely) available but clinical laboratories cannot reach the required standards. Low resources Medical history and physical examination Antibody assessment as a single diagnostic tool • Start with testing anti-tTG IgA. If negative and still suspected for celiac disease, add total IgA or DGP-IgG, if available. Diagnosis only based on symptoms and/or response to the gluten-free diet is strongly dis-couraged.
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