World Digestive Health Day WDHD – May 29, 2016 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 situation and the GFD. • Repeated duodenal biopsy to evaluate healing and for assessing 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. CELIAC DISEASE, continued • Dietary lapses are the first cause of the lack of response to the treatment. • In case of persistence of symptoms in patients with CD consider: overlapping irritable bowel syndrome (IBS) or inadvertent a wrong CD diagnosis. Consider also other diseases, such as lactose intolerance, food allergies other than wheat, pancreatic insufficiency, microscopic colitis, bacterial overgrowth, IBS, ulcerative jejunitis, enteropathy-associated T-cell lymphoma, and refractory CD. • During the first year after diagnosis 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. Cascade with resource-sensitive options for the diagnosis of celiac disease. Resource level Cascade of diagnostic options Gold standard Medical history and physical examination gluten ingestion (most common causes), but also 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 DGPIgG, if available. Diagnosis only based on symptoms and/or response to the gluten-free diet is strongly discouraged. 32 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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