Celiac disease: No cake for you!

1. Celiac disease: No cake for you! Presentation by Margaret Roberts

2. History of celiac disease • First described in 1880 • Link to diet was not described until 1950 • In 1954, Dr. Paulley showed that intestinal mucosa was damaged Walker and Murray 2010

3. Celiac Disease • Autoimmune Disease • Response to barley, wheat, and rye • It can affect the gut, skin, joints, uterus, brain, heart, and other organs • 1 in 100 have celiac disease Walker and Murray 2010

4. Diagnosis • Requires a joint clinicopathological approach • First-line test is serology with immunoglobulin A (IgA) tissue transglutaminase and IgAendomysial antibodies. • Second, biopsy is the best to confirm the diagnosis of celiac disease Walker and Murray 2010

5. Serology • While the sensitivity of IgA to detect celiac disease is 91%, this test has a positive predictive value of only 29% • In one study up to one in 13 cases of celiac disease were undetected by serology • IgA deficiency is the most common primary immune deficiency, affecting one in 400 to one in 600 of the general population, and a high proportion of those tested for celiac disease Walker and Murray 2010

6. Biopsy • Biopsy should occur in the duodenum, preferably the second portion of it. • Duodenal bulb is a secondary location • Suggested that biopsies should occur four to five times before true diagnosis can be made Classical scalloping of duodenal mucosa seen in established celiac disease at endoscopy. Walker and Murray 2010

7. Normal versus Celiac small bowel biopsy. Top: Normal small bowel biopsy with finger-like villi. Bottom: Celiac small bowel biopsy with villous atrophy and hypertrophy of crypt. Martin 2008

8. Symptoms of CD • Nausea, Diarrhea, vomiting • Irritability, fatigue • Itchy rash over arms, elbow, scalp, face and knees • Lactose intolerance, infertility, depression, and elevated liver enzymes Martin 2008

9. Side effects of CD • Have a three-fold higher risk of non-Hodgkin Lymphoma as well as cancer of the gastrointestinal tract. Lower risk of postmenopausal breast cancer because of lower obesity rates. • Iron deficiency anemia is also prevalent due to malabsorption • Worse cases have megablastic anemia because of B12 deficiency Martin 2008

10. Possible Causes: • Introduction to complementary foods too soon • Introduction to complementary foods too late • Use of formula instead of breast milk • Genes • OR … A combination of the four?

11. Introduction of Complementary foods too soon • Early in life, the body is building up immune functions as well as proper responses to food • Without the proper enzymes to digest a food, the body treats it like an antigen/allergen • Allergen exposure too early when the gut colonization and local immune networks are less established may increase the risk of allergic or autoimmune disease Prescott, Smith, Tang, Palmer, Sinn, Huntley, Cormacet. al 2008

12. Introduction of complementary foods too late • Evidence that waiting until after six months to introduce complementary foods increases food allergies • Instead, there is a critical period during which complementary foods must be introduced • Animal studies suggest this age to be 4-6 months School of Pediatrics and Child Health Research2008

13. Use of breast milk vs. formula • Studies show that breast feeding at least delays the onset of celiac disease • Continued breastfeeding promotes tolerance and have protective effects during the time when complementary feeding is initiated.

14. Celiac disease and breast milk • Breast milk may limit amount of gluten absorbed • Prevention of gastrointestinal infections by breast milk • Human milk IgA antibodies may diminish immune response to ingested gluten • The immune modulating property of human milk may be exerted through its T-cell specific suppressive effect. Selimoglu, MukadderAyse MD; Karabiber, HamzaMD 2010

15. Genes • VERY strong correlation • Virtually all patients carry human leukocyte antigen (HLA)-DQ2 or HLA-DQ8 • The absence of these molecules has a negative predictive value for celiac disease close to 100%. Walker and Murray 2010

16. Treatment • The best treatment is a gluten-free diet. This has a near 100% chance of relieving most, if not all symptoms • Unfortunately, sticking to the diet is very hard • Also, gluten-free diet is correlated with anger, sadness, and despair Selimoglu, MukadderAyse MD; Karabiber, HamzaMD 2010

17. Newest treatments • Enzyme supplement treatment • Lack of endoprolyl peptidase (PEP) • Administration of enzymes with meals can complement gastric and pancreatic enzymes in detoxification of ingested gluten • Designer carbohydrates • The aim is the production of wheat that is devoid of biologically active peptide sequences • Correction of impaired Intestinal permeability Selimoglu, MukadderAyse MD; Karabiber, HamzaMD 2010

18. Works Cited Martin, S. (May 2008). Against the grain: an overview of celiac disease. Journal of the American Academy of Nurse Practitioners. 20(5),243-50 Selimoglu, MukadderAyse MD; Karabiber, Hamza MD (January 2010). Celiac disease: prevention and treatment. Journal of Clinical Gastroenterology. 44(1), 4-8. School of Pediatrics and Child Health Research. (2008 August). The importance of early complementary feeding in the development of oral tolerance: concerns and controversies. Pediatric Allergy and Immunology. 19(5), 375-80 Walker, M. Murray, J. (3 November 2010). An update in the diagnosis of coeliac disease.Histopathology. Obtained from PubMed.gov.