Medical Care
Total lifelong avoidance of gluten ingestion is the cornerstone treatment for patients with celiac disease (CD). Wheat, rye, and barley are the grains that contain toxic peptides. They should be eliminated as completely as possible, although daily intake doses larger than 10 mg are likely needed to cause mucosal reaction. [29] GI symptoms in patients with symptomatic celiac disease who adhere to a gluten-free diet typically resolve within a few weeks; these patients experience the normalization of nutritional measures, improved growth in height and weight (with resultant normal stature), and normalization of hematological and biochemical parameters. [58]
Furthermore, treatment with a gluten-free diet reverses the decrease in bone mineralization and the risk of fractures. Symptomatic children treated with a gluten-free diet also improve their sense of physical and psychological well-being.
Of note, in recent years, the possibility of incomplete remission in many adult celiac patients has been emerging. [59] This seems, however, in most cases, still related to ongoing ingestion of minimal amounts of gluten, possibly through cross-contamination.
The results from one study noted no significant difference in thyroid autoimmunity presence in patients with CD between those on a gluten-free diet and those who were not. Although the duration of the diet differed significantly in patients with thyroid autoimmunity from those without it, this did not seem to affect weight and height gain. These results suggest that universal long-term screening programs for thyroid disease may only be necessary when thyroid diseases are suspected. [60]
The complete safety of oats has been well established by a large body of scientific evidence obtained from in vitro studies as well as from clinical investigations (particularly in adults but also in children). However, because of uncontrolled harvesting and milling procedures, as well as the possibility that lines of manufacturing used for wheat-based flours are also used in the preparation of oat-based foods, cross-contamination of oats with gluten is still a concern, and patients should be careful in selecting oat products that are certified to be gluten-free.
Lactose is often eliminated in the initial phases of dietary treatment as well. This is because lactase deficiency is thought to accompany the flat mucosa. However, most newly diagnosed patients with celiac disease are diagnosed in the absence of overt malabsorptive symptoms; in these circumstances, clinically significant lactose malabsorption or intolerance is rarely seen. Furthermore, even in cases with obvious malabsorption, the recovery of lactase activity is typically fast; thus, a lactose-free diet must be used on a short-term basis only, even in these individuals.
The Academy of Nutrition and Dietetics (AND) (once American Dietetic Association (ADA)) publishes guidelines for the dietary treatment of celiac disease. They are a reliable source of information for a gluten-free diet. However, because of the dynamics of this field, the diet requires ongoing collaboration between patients, health care providers, and dietitians.
Consultations
Because of the protean nature of celiac disease, multiple consultations may be initially necessary. For example, consultations with an endocrine specialist should be arranged for patients who also have Hashimoto thyroiditis or type I diabetes mellitus, and a rheumatologist must be consulted for patients who have arthritis.
Activity
No additional restriction is necessary beyond that imposed by the patient's fatigue. However, if a completely gluten-free diet is followed, celiac disease in the majority of cases fully regresses, allowing all normal activities.
Prevention
The only way to prevent recurrences is to closely monitor the patient's diet. Because celiac disease is more common in relatives of patients, first-degree relatives should at least be serologically screened. Concerned parents usually accept this simple procedure, which often reveals previously undetected celiac disease, even in asymptomatic individuals. This effective preventive strategy must be encouraged.
Also, prevention of complications by early diagnosis (secondary prevention) may be achieved by applying a protocol of blood screening to all patients who belong to other at-risk categories (eg, type 1 diabetes mellitus, Down syndrome).
With elucidation of the role that infant feeding practices and viral infections play, primary prevention of celiac disease no longer seems impossible. In fact, future strategies may be envisaged based on protection from infections, manipulation of microbiota, and intervention on T cells. [61]
Long-Term Monitoring
After the diagnosis of celiac disease (CD) has been established and a strict diet has been initiated, the first follow-up requirement is to monitor the patient's response to the diet. Depending on the severity of the clinical situation and the type of symptoms, the first outpatient appointment is typically scheduled 3-4 months after the diagnosis. [57] At this time, serologic tests (tTG-IgA and deamidated gliadin peptides [DGP]) are typically checked, along with tests that had abnormal results at the time of diagnosis. A full physical examination with anthropometric measurement and, additionally, an appointment with an expert dietitian are highly recommended to iron out any uncertainties about the diet.
Further follow-up appointments
If no problems are observed at the first follow-up appointment, visits may occur after 6-12 months. Again, tTG-IgA and DGP should be periodically monitored for regression; their levels usually halve in about 4-6 months after the beginning of a strict diet. However, the best indicator of dietary compliance is attainable by a careful review of the diet, and simple survey questionnaires have been developed for use in adults. [62] For patients whose initial levels of anti-tTG were particularly elevated, normalization can take up to more than 12-18 months. For asymptomatic patients and for those who are clinically responding well to diet, follow-up appointments are usually scheduled annually.
Celiac disease can be associated with numerous autoimmune disorders. If any are present (eg, type I diabetes mellitus, thyroiditis), follow-up care must include an adequate assessment of these conditions, which most often do not respond to the diet, and referral to other specialists is required (see Consultations).
In patients who had obvious malabsorption at diagnosis, assessment of the status of specific nutritional deficiencies (eg, iron deficiency, folate deficiency, zinc deficiency) is appropriate.
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Potbelly and muscle wasting in a child with celiac disease.
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The celiac iceberg.
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Presentations of celiac disease.
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Extraintestinal manifestations of celiac disease.
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GI signs and symptoms of celiac disease.
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Approximate prevalence of celiac disease in other autoimmune disorders.
Tables
GI Manifestations |
Systemic and Extra-GI manifestations |
Abdominal distention Abdominal pain Diarrhea Vomiting Constipation Anorexia Intussusception “Celiac crisis” Aphthous ulcers/ Geographical tongue Dental enamel hypoplasia |
Fatigue Weight loss/Failure to thrive Anemia Vitamin D deficiency Delayed puberty Short stature Dermatitis herpetiformis Reduced bone mineral density Arthritis, arthralgia Abnormal liver enzymes/Autoimmune Hepatitis Neurologic
Psychiatric
|
Autoimmune conditions |
Genetic/Chromosomal disorders |
Other disorders |
Type 1 diabetes mellitus Thyroid disease:
Systemic lupus erythematosus Juvenile idiopathic arthritis Autoimmune skin disorders
|
Selective IgA deficiency Down syndrome Turner syndrome Williams-Beuren syndrome |
Eosinophilic esophagitis Asthma Gastroesophageal reflux Pancreatitis |
