“If a 30year-old patIent has osteoporosIs, physICIans should ConsIder undIagnosed CelIaC dIsease as a possIble CulprIt.” – David Doman, M.D., FACP, FACG
weight loss and diarrhea, while adults commonly have symptoms that manifest outside the GI tract. An adult’s only symptoms may be migraines, depression, ADHD, recurring miscarriages or infertility, or skin disorders such as unexplained hives, uticaria or dermatitis herpetiformis. Many people have genetic susceptibility to celiac but never get the disease. According to Dr. Doman, “It’s still unclear what the trigger is and why some patients get celiac as children while others are affected as adults. It’s likely that some mutations are more aggressive than others.” Malabsorption of Vitamin D, folic acid and other nutrients can cause osteoporosis at a young age. “If a 30-year-old patient has osteoporosis, physicians should consider undiagnosed celiac disease as a possible culprit,” he advises.
issue when the patient has adhered to a gluten-free diet or is taking immunosuppressants.” He also warns physicians against interpreting positive genetic test results as indicative of celiac. “A positive test only means that the individual is at higher risk for celiac. It’s only helpful in ruling out celiac when the test finds the patient to be free of celiac-related mutations.” Dr. Doman adds, “The gold standard in diagnosing celiac disease continues to be the small bowel biopsy. The endoscopic procedure takes about half a dozen random biopsies, and histologic changes can range from mild with lymphocytic infiltration, to complete villus atrophy. The patient can have a complete absence of villi in the most extreme cases.”
TREATMENT In 2014, the standard of care is a lifelong gluten-free diet. While many patients find this diet provides compliance challenges, gluten-free food is far more readily available at most supermarkets or online today than in the past. Phase 2 and Phase 3 clinical trials are currently underway on a number of fronts to develop new treatment approaches, including the following:
in pregnancy and IBD. Mary Harris, M.D., medical director, The Center for Inflammatory Bowel and Colorectal Diseases at Mercy Medical Center, is one of the few. “I became an expert by default because other colleagues didn’t want to deal with this issue,” she says. “Crohn’s and colitis are almost invariably diagnosed in people of childbearing years, and it takes careful planning for these patients to have a successful pregnancy and birth.” Fortunately, with good care and planning, it’s entirely possible for most women with IBD to conceive. “However, patient education and planning is a requisite,” Dr. Harris emphasizes. “Patients must be in remission for at least three months before getting pregnant, and folic acid prior to conception is even more important for this group than for the general population.” “These patients have high anxiety levels,” Dr. Harris explains. “And David Doman, M.D., FACP, FACG, clinical professor of Medicine, George Washington University School of Medicine
z New types of genetically engineered wheat that will not cause the inflammatory cascade z Therapeutic probiotics that can metabolize gliadin z A therapeutic vaccine that can induce gluten oral tolerance z Transglutaminase inhibitors for targeted immune suppression z Antizonulin therapy to restore small bowel cellular junction integrity
DIAGNOSIS Diagnostic tests can include serologic testing, malabsorption screening, genetic testing, radiographic evaluation, wireless capsule endoscopy and small bowel biopsy. Dr. Doman cautions, “No single laboratory test can completely establish a diagnosis of celiac disease. Antibody testing is only 90 to 95% reliable, and false negatives are an
Today, a strict gluten-free diet is mandatory for successful treatment, but these new clinical trials present hope for other options in the future,” Dr. Doman concludes.
PREGNANCY AND IBD Given the thousands of gastroenterologists in the country, perhaps it’s surprising that only a handful specialize
MARCH/APRIL 2014
| 19