Celiac Disease (Week 4 GI)

Question 1

What is celiac disease?

Answer 1

an immune-mediated enteropathy caused by a permanent sensitivity to gluten in genetically susceptible individuals
* Disease of the Small Intestine; jejunum Is major site

Question 2

How to symptoms present in celiac disease?

Answer 2

occurs in symptomatic subjects with GI and non GI symptoms
* About 50% present Gi symptoms and 50% present with other symptoms

Occurs in some asymptomatic individuals
* screened because of risk factors

Question 3

What are DQ2 and DQ8?

Answer 3

The HLA gene alleles that predispose a person to celiac disease
* DQ2 and/or DQ8 positive HLA haplotype is necessary but not sufficient → The majority of people who test positive for HLA-DQ2/DQ8 are at risk, but only 2% to 3% actually develop celiac disease

Question 4

What is the environment trigger of celiac disease?

Answer 4

gluten

Question 5

What is the autoantigen detected in celiac disease?

Answer 5

tissue transglutaminase
* The immune system mistakenly thinks that gluten — a protein in wheat, barley, rye, and oats — is a foreign invader.

Question 6

What can result in complete resolution of celiac disease?

Answer 6

elimination of gluten

Question 7

Diagnosis of Celiac disease

Answer 7

Question 8

pathogensis of celiac disease

Answer 8

Presentation of modified gliadin peptide in context of HLA-DQ2 leads to activation of CD4 + T-cells (both circulate to attack foreign things)
* Also humeral response has a role

Question 9

What is tTG and how does celiac disease affect it?

Answer 9

TTG is a normal gut enzyme that that is released during injury to fix damages but in celiac disease autoantibodies work againsts TTG correlating with active disease.
* tTG IgA antibody concentrations greater than 40 U/m correlate with celiac disease diagnosis

Question 10

What are absorption pathophysiology complications of celiac disease?

Answer 10

• Malabsorption of nutrients, especially iron, folate, Ca and vitamin D
• Malabsorption of fat, fat soluble vitamins
• Increased intestinal permeability may permit entry of other antigenic stimuli which might induce autoimmune diseases

Question 11

prevalence of celiac disease

Answer 11

• 1-3%, highly prevalent in South Asian, Sahara European Ancestry (pakistan probably highest)
• 1-2/100 in Canada
• 4-8/100 in Sweden
• ~8/100 in India

Question 12

risk factors for celiac disease

Answer 12

• First degree relatives of celiac disease patients
• Type 1 DM
• Down syndrome
• Turner syndrome
• William syndrome
• Selective IgA deficiency

Question 13

What are typical symptoms of celiac disease?

Answer 13

62% experience typical symptoms
* Abdominal pain
* diarrhea
* failure to thrive

Reason for screening in addition → 4%

Question 14

What are atypical symptoms of celiac disease?

Answer 14

6% experience atypical symptoms
* Iron deficiency
* headache
* tremors
* fatigue (energy delivery malfunctions)
* constipation
* depression (mental health)

Reason for screening in addition - 22%

Question 15

How many with celiac disease might experience no symptoms?

Answer 15

~34%
* A reason for screening only

Question 16

What is asymptomatic celiac disease often referred to as?

Answer 16

The tip of the iceberg → Can be either silent or latent celiac disease
* Silent: no or minimal symptoms, damaged mucosa and positive serology
* Latent: no symptoms, normal mucosa and may show positive serology

Will develop later mucosal changes and/or symptoms

Question 17

What GI manifestations might occur with celiac disease?

Answer 17

• Chronic or recurrent diarrhea
• Abdominal distension
• Anorexia
• FTT or weight loss
• Abdominal pain
• Vomiting
• Constipation
• Irritability (mental health)
• poor microbiome

Question 18

What is the most common non-GI manifestation?

Answer 18

iron deficiency anemia (3-5%)
* higher in children with newly diagnosed celiac disease anemia is common

Question 19

Aside from iron, what are other non-GI symptoms?

Answer 19

• Hepatitis (liver disease - uncommon)
• Arthritis
• Epilepsy with occipital calcifications
• Poor Bone Health and in adults ↑ risk for fracture (no evidence in children)
• Mental Health: brain fog
• Poor dentition (from GERD)

Question 20

What is a physical sign for celiac disease?

Answer 20

dental enamel defect
* Involve the secondary dentition
* Could be the only presenting sign of celiac disease - sometimes how kids are diagnosed
* may be from experiencing GERD

Question 21

How does celiac disease disrupt growth in children/ teens?

Answer 21

short stature and delayed puberty:
* About 10% of short children and teens have evidence of celiac disease
* Delayed menarche
* Higher prevalence in teens with untreated celiac disease
* signs of osteopenia
* poor bone development (not symptom dependent)

Question 22

What should healthy bone be composed of, and how should it grow?

Answer 22

• New born skeleton has 25 grams of calcium → Adult skeleton has 1200 grams of calcium
• Increase bone mass 30 x during childhood → Further 50% accrual of that to date during adolescence

Question 23

What is the importance of early diagnosis?

Answer 23

• Improved quality (and length) of life
• Improved growth
• Improved learning ability
• Decreased risk of other auto-immune disorders
• Early diagnosis – in childhood – may decrease the risk of complications
• Osteoporosis
• Early diagnosis – in childhood – may increase adherence with a gluten free diet

Question 24

How is celiac disease managed?

Answer 24

Gluten free diet (GFD) remains best treatment
* Controversies over analytical methods to measure and define gluten content → <20ppm can be labelled gluten free
* Commercial recognition “value” of gluten free products
* How much can I cheat?
* The GFD has several nutritional limitations

Question 25

What is the problem with oats?

Answer 25

Oats do not contain gluten but are a problem due to high risk of contamination from nearby wheat fields and milling processes (common for them to be in proximity) * Needs to have gluten free label; those of unknown purity should be avoided * Contains avenin which is similar to gluten but considered okay in small amounts * tolerance may be dose dependent - >60g/d associated with disease recurrence * Usually recommended to avoid oats for the first 6 months-1 year of starting GF diet then can add in small amounts

Question 26

Canadian Celiac Association position on pure and uncontaminated oats?

Answer 26

Must not be introduced until disease is considered “stable” * Must not exceed 50g to 70g (1⁄2 cup to 3⁄4 cup) daily for adults or 20 to 25g (1⁄4 cup) for children * Gastrointestinal symptoms must be monitored during oat introduction * Small # of individuals will not tolerate oats

Question 27

What skin condition might result from skin products containing gluten?

Answer 27

Dermatitis Herpetiformis * Erythromatous papule → urticarial papule → tense vesicles * Symmetrical with severe pruritis * 90% no GIsymptoms * Gluten sensitive * 75% villous atrophy

Question 28

What is gluten?

Answer 28

A group of storage protein * Wheat – gliadin * Rye – secalin * Barley - hordein

Question 29

What does gluten do?

Answer 29

* Gluten forms a network which gives bread dough its elasticity (more light and fluffy) * Carbon dioxide trapped within the network produces light and fluffy baking * Gluten contributes to the chewy and soft texture of a product

Question 30

What are macronutrient concerns of GF diet?

Answer 30

* Higher saturated fat (trying to make up for CO2 molecules not being trapped) * Total Sugar Intake * Low Fiber Intake * Usually higher glycemic index

Question 31

What micronutrients are at risk in GF diet?

Answer 31

* vitamin D * vitamin K * Folate

Question 32

How does GF diet change the the food plate?

Answer 32

veggies and fruit take up more than half the plate and less given to GF grain foods to make up for lack of folate

Question 33

What supplements are reccommended in a GF diet?

Answer 33

* Multivitamin –needs to include folate * Calcium * Vitamin D * Fiber (ex. Metamucil)

Question 34

What are GF grains and seeds

Answer 34

Question 35

What are gluten containing products to avoid?

Answer 35

Question 36

What are some potential non-food sources of gluten?

Answer 36

Question 37

what are common spots for cross-contamination of gluten?

Answer 37

For those following a strict gluten-free diet, cross contamination is a potential concern. * Deep fryers, buffets, shared cutlery, toasters, peanut butter/jam jars.

Question 38

What is the importance of label reading

Answer 38

* Always read the ingredient lists on a product to ensure it’s gluten free * Look for GF symbols on the product

Question 39

What are common key words for GF label reading?

Answer 39

* whole grain oats → not gf oats * soluble wheat → wheat listed in ingredients * natural flavour → something could be hidden here * malt flavoring → malt = barley * contains soy and wheat ingredients → other area where companies have the option to list allergens

Question 40

How are GF products claimed?

Answer 40

medical expenses claim * letter confirming celiac disease * summary sheet of purchases * receipts to support claim

Question 41

How to travel with CD?

Answer 41

* Look on-line for a Celiac Chapter in the city you are travelling to → Contact chapter for restaurant info; “Google” gluten-free restaurants * Call the hotel/resort and explain your gluten intolerance → Ask to speak with the chef and meet upon your arrival; Many restaurants in the United States offer for the chef to come speak to you * Ask for a fridge for your room if you don’t have a kitchenette

Question 42

What to bring while travelling if GF

Answer 42

* Breakfast cereal with added dried fruit, nuts and seeds * Loaf of toasted bread toasted with slices wrapped individually * Snack bars, trail mix, cheese strings * Condiments in Tupper-ware containers margarine, peanut butter, soy sauce, mayonnaise