Celiac Disease (CD) is what?
an immune disorder that is triggered by an environmental agent (the gliadin component in gluten) in genetically predisposed individuals
Describe the pathway for wheat digestion
Serologic studies are used to follow the course of the disease: 2
1. IgA antibodies to gliadin
2. IgA antibodies to endomysium
WHat are IgA antibodies to endomysium?
A structure of the smooth muscle connective tissue
-Its presence is nearly pathognomonic for CD
Gliadin receptors on intestinal epithelial cells may mediate what?
transport of gliadin peptides into the lamina propria where T cell activation occurs—this may someday lead to drug therapy for CD
Which is a normal small intestine and which as celiac?
Describe the PP of Celiac Disease
CD Classic Clinical manifestations
1. Diarrhea w/ bulking, foul-smelling, floating stools due to steatorrhea (malabsorption)
2. Weight loss
3. Vitamin deficiencies—B vitamins, iron, copper, zinc, vitamins A, D, E, & magnesium
4. On small bowel biopsy—villlous atrophy
Atypical Manifestations of CD?4
1. Minor GI symptoms
2. Can have anemia, osteoporosis, arthritis
3. Increased LFTs, neurological symptoms, or infertility
4. Most show severe mucosal damage & possess the CD antibody pattern
1. Silent CD is recognized how?
2. Often have changes in what?
3. How do they usually present?
1. Recognized incidentally based upon screening for antibodies
2. Often have some changes in mucosa of the small bowel
3. They DO NOT show clinical symptoms but may complain of fatigue
Several studies have shown that patients with CD have a slight increased of malignancies: such as? 6
(but what is there a decrease in?)
1. Non-Hodgkin’s lymphoma
2. Small intestinal adenocarcinoma
3. Hepatocellular carcinoma
4. GI cancer
5. Lymphoproliferative disease
6. Hodgkin lymphoma
Studies also showed a DECREASED risk of breast cancer!
Associated Conditions with CD?
1. Dermatitia herpetiformis (autoimmune rash)
2. Type I DM
3. Down syndrome
4. Liver disease
5. Autoimmune thyroid disease
7. Inflammatory bowel disease
8. Menstrual and reproductive issues in women
9. Infertility in men
What is this a picture of?
1. What should we begin with?
2. What are these?
3. Used in what ages?
1. Begin w/ IgA anti-tissue transglutaminase (TTG):
2. Auto-antibodies against the bodies on tranglutiminases***
3. Used for anyone over the age of 2
Single preferred test for detection of CD!
If High probability of disease & if IgA based serology is negative: What tests should we do? 2
1. Test Total IgA or
2. IgG-deaminated gliadin peptides (DGP)
1. Patients w/ POSITIVE serology should undergo what?
2. from where? 2
1. small bowel biopsy
-1-2 biopsies from the duodenal bulb
-At least 4 from the 2nd and 3rd portion of the duodenum
1. Patients on a gluten free diet who have NEGATIVE serology's—should have what done?
2. What is this used to determine?
3. If negative?
1. HLA/DQ1/DQ8 testing:
2. Determine if the patient is genetically susceptible to the disease
3. If negative CD is ruled out
If the serology is positive but the small bowel biopsy is negative the patient can be managed how?
high gluten diet and be re-biopsied after 6-12 wks.
1. Individuals w/ low pretest probability (purely Chinese, Japanese and Sub-Saharan African descent): recommend what kind of testing?
1, recommend—IgA endomysial antibody test:
2, It has higher specificity
3. It is more costly
Some people are “sensitive” to gluten without having CD. How do they present?
They get diarrhea, feel “ILL” and bloated and find if they eliminate gluten from their diet they feel better
Treatment—6 key elements
1. Consultation w/ a skilled dietitian
2. Education about the disease
3. Lifelong adherence to a gluten free diet
4. Identification and treatment of nutritional deficiencies
5. Access to an advocacy group
6. Continuous ongoing follow-up by a multidisciplinary team
General Rules for Gluten Free
1. Foods containing wheat, rye and barley AVOID
2. Soybean or tapioca flours, rice, corn, buckwheat and potatoes are safe
3. READ labels
4. Distilled alcohol, vinegar, and wine are gluten free
5. Beers, ales, lagers, and malt vinegars should be avoided because they are often made w/ gluten grains
6. Dairy products may not be well tolerated initially since many patients w/ CD can have secondary lactose intolerance—initially dairy should be avoided
7. Oats should be introduced into the diet w/ caution
Symptoms: (due to low levels of lactase in small bowel)
2. Abdominal pain
What causes lactose intolerance symptoms?
Unabsorbed lactose in the large intestine
Developmental lactase deficiency:
1. Results from what?
2. Infants born at _____ weeks gestation have reduced lactase activity
1. Results from low lactase levels as a result of prematurity
Congenital lactase deficiency:
1. Inherited how?
2. What is the PP?
1. Rare autosomal recessive disorder
2. Absence of any lactase activity in the small intestine
Secondary lactase malabsorption:
1. Bacterial overgrowth or stasis may be associated w/ what?
2. Seem w/ any mucosal injury to the small bowel such as what? 3
1. increased fermentation of dietary lactose in the small bowel
Clinical Manifestations of lactose intolerance?
1. Abdominal pain—crampy, usually periumbilical and lower quadrants
5. Vomiting—in adolescents
Diagnosis for lactose intolerance? 2
1. Lactose tolerance test:
2. Lactose breath hydrogen test:
Describe the lactose tolerance test:
1. Process? 2
2. Positive result is?
-50g test dose given in adults
-Blood glucose levels drawn at—0, 60 and 120 minutes
2. An increase in blood glucose by less than 20 mg/dL plus symptoms is diagnostic
3. Cumbersome and time-consuming
Describe the Lactose breath hydrogen test:
1. Process? 2
2. what is a positive result?
-Oral lactose given in fasting state [2 gm/kg—max 25 mg]
-Breath hydrogen levels measured at baseline and 30 min intervals for 3 hrs. after lactose ingestion
2. Values over 20 ppm diagnostic
Treatment for lactose intolerance?
1. Dietary restriction of lactose intake:
-Usually some lactose containing foods [cheese] can be tolerated
2. Substitution of alternative sources to maintain energy and protein intake
3. Administration of commercially available enzyme substrate**
4. Maintenance of calcium and Vit D intake
1. What is ileus?
2. Etiologies? 7
1. Definition: temporary absence of the normal contractile movements to the intestinal wall
-Postoperative—especially abdominal when the intestine’s have been manipulated
-Drugs: opioids and anticholinergics
-Electrolyte disorders—hypokalemia, hypercalciemia
Clinical Manifestations of ileus?
3. Crampy abdominal pain—pain precedes vomiting when associated with acute surgical etiology
4. Severe constipation
5. Loss of appetite
1. Adynamic [Paralytic] Ileus
2. Intestinal obstruction
3. Acute abdomen
4. Post-op adhesive disease
How do we diagnosis ileus?
4. CMP including magnesium
Treatment for ileus?
1. NPO advancing to clear liquids as tolerated
2. IV fluids to maintain hydration and correct electrolyte abnormalities
3. Stop drugs that make the ileus worse
4. Occasionally NG tube