57 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 Kamut, Einkorn, Emmer Graham flour, rye, or barley (including malt, malt extract, malt flavoring, and malt syrup). Gluten-free grains, flours, and starches that are allowed in a gluten-free diet include: amaranth, arrow-root, bean flours, buckwheat, corn, garbanzo beans, seeds, millet, Monti-na flour (Indian rice grass), nut flour, nut meals, oats (uncontaminated), potato flour, potato starch, quinoa, rice ( all forms), sorghum flour, soy flour, tapioca, and teff flour. A small subgroup of patients with CD may also be intolerant to pure oats. Oats must be pure and uncon-taminated by gluten to be suitable per most CD patients. The majority of industrially pro-duced foods may contain gluten. Any dietary deficiencies, starting from the correct fiber content, but also iron, folic acid, calcium, and (very rarely) vitamin B12, should be corrected. DIFFERENTIAL DIAGNOSIS In absence of a positive serology, the histological lesions suggestive of CD may suggest the presence of condi-tions other than CD. The differential diagnosis includes infective diseases (tropical sprue, giar-diasis, cholera, H. pylori, HIV), im-munodeficiency states, drug-induced enteropathy (olmesartan, mycopheno-late, chemotherapy), allergy (eo-sinophilic gastroenteritis, in children enteropathy caused by food allergy), radiation damage, graft-versus-host disease, chronic ischemia, Crohn’s disease, and autoimmune enteropathy. EXTRAINTESTINAL MANIFESTATIONS AND COMPLICATIONS There are increased risks for unex-plained infertility (12%), osteoporosis (30–40%), and bone fractures (35%) in classically symptomatic CD. Pa-tients with (long-term untreated) CD have an elevated mortality risk due to an increased risk for malignancy. In particular, CD has been related to higher risk of malignant lymphomas, small-bowel adenocarcinoma, and oropharyngeal tumors. Likely, less than 1% of diagnosed patients may develop a severe complication called refractory CD, which is defined as persistence or recurrence of clini-cal symptoms and histopathological abnormalities despite excellent adher-ence to GFD for at least 12 months. Refractory CD must be considered, particularly in patients with CD diag-nosed over the age of 50. This compli-cation should be differentiated from the very common non-responsive CD, which often is the consequence of persistent gluten intake (intentional or non-intentional) (see below). MANAGEMENT OF CELIAC DISEASE The vast majority of CD patients report an improvement in symptoms within few weeks after starting the GFD. Although most patients have a rapid clinical response to a GFD, the rate of response varies. Patients who are extremely ill may require hospital admission, nutritional support, and, occasionally, steroids. With strict dietary adherence, the titer of CD-specific antibodies falls. The complete histological resolution, however, may take years and may not be achieved in every patient. There is evidence that the lack of histological resolution could be determined by persistent consumption of gluten. Key issues when following up CD are: • Serological tests cannot detect minimal gluten intakes (traces), so expert physicians and nutritionists should evaluate of the clinical situ-ation and the GFD. • Repeated duodenal biopsy to evaluate healing and for assess-ing adherence to a GFD is a controversial area among experts. However, intestinal biopsy should be considered as mandatory in patients persisting with symptoms despite evidence of strict GFD. • Dietary lapses are the first cause of the lack of response to the treat-ment. • In case of persistence of symptoms in patients with CD consider: overlapping irritable bowel syn-drome (IBS) or inadvertent gluten ingestion (most common causes), but also a wrong CD diagnosis. Consider also other diseases, such as lactose intolerance, food aller-gies other than wheat, pancreatic insufficiency, microscopic coli-tis, bacterial overgrowth, IBS, ulcerative jejunitis, enteropathy-associated T-cell lymphoma, and refractory CD. • During the first year after diag-nosis of CD it is important to check symptoms and laboratory tests (best predictors: quantitative determination of anti-DGP IgA and anti-tTG IgA) and, if possible, to visit a nutritionist. • In women, a DEXA bone mineral density scan serves as a baseline measure of bone mass. • Facilitate the approach to support groups for CD patients. • If necessary and/or requested, offer a psychological consultation.
To see the actual publication please follow the link above