Stat Consult: Celiac disease
Photomicrograph showing complete atrophy of the duodenal villi.
- In infants
- Growth retardation
- Failure to thrive
- In children
- Short stature
- Delayed puberty
- Most patients are thin
- Dermatologic findings such as xerosis or keratosis pilaris
- Abdominal distention may occur
Making the diagnosis
- A presumptive diagnosis is based on a combination of clinical presentation and positive serology (tissue transglutaminase or antiendomysial antibody tests).
- Distal duodenal biopsy is needed to confirm diagnosis.
- All initial serology testing and biopsies should be performed before starting gluten restriction.
- Rotavirus gastroenteritis
- Immunologic conditions
- Allergic enterocolitis (milk protein allergy, soy allergy, rice allergy)
- Breast milk intolerance
- Collagenous colitis
- Lactose intolerance
- Tropical sprue
- Pancreatic insufficiency
- Crohn's disease
- Microscopic colitis
Testing to consider
- Serologic testing
- IgA tissue transglutaminase antibody (tTG)
- IgA antiendomysial antibody (EMA)
- If antibody testing is positive, confirm with distal duodenal biopsy.
- Positive findings on biopsy include: Villous atrophy; flattening of mucosa ; lymphocytes and plasma cells in lamina propria ; increased mitoses in crypts
- If negative IgA tTG or IgA EMA and celiac disease is still suspected
- Serum IgA level (if selective IgA deficiency, immunoglobulin G [Ig]G, tTG or IgG EMA can be used)
- HLA genetic testing (absence of DQ2 or DQ8 alleles rules out celiac disease)
- Upper intestinal endoscopy and distal duodenal biopsy if otherwise warranted
- Testing for nutritional deficiencies (hemoglobin, iron, folate, calcium, vitamin D)
- Radiographic studies are not necessary for celiac disease, but may be used to rule out other diagnoses.
- Lifelong gluten-free diet recommended
- Avoid all foods containing wheat, rye, and barley gluten
- Avoid all foods containing oats and lactose initially
- Avoid beers, lagers, ales, and stouts
- Other foods that may include gluten include dextrins, malt, and caramel coloring.
- Beware of gluten in medications, and in food additives, emulsifiers, and stabilizers.
- Wheat flour may be used in many prepared foods including canned products, salad dressings, and ice creams.
- Use only rice, corn, maize, buckwheat, potato, soybean, or tapioca flours, meals, or starches.
- Look for foods with the gluten-free symbol.
- Try wheat starch with gluten removed, oats, and lactose after diagnosis is established.
- The amount of gluten that causes symptoms varies among patients with celiac disease.
- Strict adherence to a gluten-free diet for more than five years may reduce risk for non-Hodgkin lymphoma.
- Oats in diet appear safe in controlled trials, but some patients may have oat intolerance and commercial oats are often contaminated with gluten.
- Treat nutritional deficiencies with special attention to iron, folate, and vitamin B12.
- Addition of budesonide to a gluten-free diet may improve symptoms in patients with celiac disease with malabsorption
- Limited evidence for immunosuppression therapy (e.g. azathioprine, infliximab, cyclosporine) for refractory celiac disease
- Refer patient to experienced dietitian
- Refer patient to support group
- In patients with newly diagnosed celiac disease who also have anxiety and depression, adding psychological support when starting a gluten-free diet is associated with lower rates of depression after six months.
- Gluten-free camp attendance reported to improve quality of life in children with celiac disease
- Monitor patients for improved symptoms in response to a gluten-free diet (expected after six to 12 months)
- Monitor dietary compliance
- Check bone mineral density to assess for osteoporosis
Brian Randall, MD, is a clinical editor for DynaMed, a database of comprehensive updated summaries covering more than 3,200 clinical topics, and Assistant Clinical Professor of Family Medicine at Tufts University School of Medicine.