World Digestive Health Day WDHD – May 29, 2016 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) The CD serology encompasses serological markers targeting the auto-antigen, such as antiendomysial (EMA) and anti-tissue transglutaminase (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). Specifically, IgG-based tests are useful for detecting CD in selected IgA-deficient patients. It is recommended to test also the level of the serum total IgA, as IgA deficiency is present in 2% of population. In case of selective IgA deficiency in a second blood samples, IgG-based tests should be performed (anti- DGP, anti-tTG or EMA) because negative IgA antibodies will not be diagnostic. CELIAC DISEASE, continued Patients having a low titer of antibodies, and having histologically normal mucosa, may be a false positive test. The recommendation is to repeat the serology after six months while on a gluten-containing diet. If serology remains to be positive, these patients may be called potential CD and they should be followed. Majority of potential CD patients later develop the disorder. The long-term follow up of such patients is not well known. The intestinal (duodenal) biopsy has been considered as essential for diagnosing CD. CD predominantly affects the mucosa of the proximal small intestine, with damage gradually decreasing in severity towards the distal small intestine. Under light microscopy, the most characteristic histological findings in patients with CD who are taking a gluten-containing diet are: • Increased density of intraepithelial lymphocyte (>25/100 epithelial cells) • Crypt hyperplasia with a decreased villi/crypt ratio • Blunted or atrophic villi • Mononuclear cell infiltration in the lamina propria • Epithelial changes, including structural abnormalities in epithelial cells. A modified Marsh classification for villous abnormalities is now widely used for assessing the severity of villous atrophy in clinical practice. It is highly recommended that the pathologists include report changes in a structured format, including the abovementioned histological changes, intraepithelial lymphocytes count, and interpretation in terms of modified Marsh´s classification. A negative histological diagnosis may justify a second biopsy in selected patients who have positive autoantibodies, such as high titre anti-tTG, anti-DGP, and/or endomysial antibodies. Patients with dermatitis herpetiformis having a positive serology may have normal histology. Upper endoscopy, performed for other causes than biopsy procuration, may show scalloping and/or flattening of duodenal folds, fissuring over the folds, and a mosaic pattern of mucosa of folds. Four to six biopsy samples must be taken from the second part of the duodenum, and from the duodenal bulb, even if the mucosa appears normal. Biopsies must be taken when patients are on a gluten-containing diet (e.g. two slices of toast per day during four weeks). The intestinal biopsy is always necessary if the antibodies are negative. However (and according to very new concepts for children), biopsies may be omitted in the presence of symp- 30 WGO Handbook on DIET AND THE GUT World Digestive Health Day WDHD May 29, 2016
WGO Handbook on Diet and the Gut_2016_Final
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