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Disclosures

Managing Celiac Disease and Wheat Sensitivity

• None relevant to this presentation

Robert Berger MD FRCPC Dalhousie CME November 2, 2016

Objectives

Case 1

• Review the epidemiology and clinical presentation of Celiac disease • Diagnostic approach • Pathophysiology and immune aspects • Discuss associated conditions and complications • Is non-Celiac gluten sensitivity a real thing?

• 24yo female diagnosed 3 yrs ago with IBS. • Describes frequent abdominal gas and bloating. • Variable bowel habit • Weight stable • CBC normal • Anti-tTG=75

Case 2

History of Celiac Disease

• 54yo female with 24 year h/o Celiac disease • Says she is compliant with GFD • Presents with 7 month h/o diarrhea

• 1st century

• 6-7 watery BMs daily • Weight stable

• Recognized by Aretaeus the Cappadocian

• 18th century • “sprue” described

• 1888 • “On the Coeliac Affection” by Samuel Gee

• What is the differential diagnosis? • What are the next steps in investigation?

• 1940s • Link to diet made by Willem Karl Dicke

• 1952 • Van de Kamer links Celiac to gluten

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Terminology

Clinical Presentation

• Celiac sprue • Non-tropical sprue • Gluten enteropathy • Gluten-sensitive enteropathy • Endemic sprue • Gee Herter syndrome

• GI symptoms • • • •

Diarrhea Bloating/gas Weight loss Dyspepsia-type symptoms

• Non-GI manifestations

Non-GI Manifestations • Iron deficiency • Metabolic bone disease • Neuropsychiatric symptoms • Neuropathy, ataxia, depression, anxiety

• Liver disease

Fasano A. Curr Opin Gastroenterol 2006.

Iron deficiency anemia

Associated Conditions

• 10-15% in Celiac patients with GI symptoms • 5 of asymptomatic IDA have Celiac • Approx 10% of premenopausal women with IDA have Celiac

• Type 1 DM • Autoimmune thyroid disease • Down syndrome • Renal disease • Interstitial lung disease • Idiopathic pulmonary hemosiderosis • Hyposplenism • PBC • Recurrent pericarditis

Rostom et al. Gastro 2006.

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Screening High-Risk Populations Population

Percent affected

General

0.7-1.0%

1st degree relative with CD

4-12%

2nd degree relative with CD

2-4%

Down syndrome

5-16%

Type 1 DM

5-10%

Autoimmune thyroid disease

4-5%

IgA deficiency

2-8%

Pathogenesis

Rostom et al. Gastro 2006. Sleisinger and Fordtran 2010.

Diagnosis

Diagnosis - Serology

• Serology • HLA typing • Endoscopy

• Anti-endomysial • IgG and IgA

• Anti-gliadin • IgG and IgA

• Anti-TTG • IgG and IgA

• Anti-DGP • IgG and IgA

Serologic testing

What about IgA deficiency?

• IgA AGA

• 30pt increase in symptoms

• 2 control groups: 1 with IBS, 1 with Celiac

Carroccio et al. Am J Gastro 2012.

• 920 patients underwent wheat challenge • 30% of IBS patients undergoing testing had wheat sensitivity (276/920) • 70 patients had WS alone • 206 patients had additional sensitivities • 206 included cow’s milk proteins • Eggs and tomato most common otherwise

Carroccio et al. Am J Gastro 2012.

Carroccio et al. Am J Gastro 2012.

Symptoms of Wheat Sensitivity • Myalgias • Headache/Migraine • Lethargy • Fatigue • Sleep disturbance • Joint pain

Bizzaro et al. Clinic Rev Allerg Immunol 2012.

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• 92 patients with IBS-D by Rome III criteria • 4 week comparison of a modified NICE vs low FODMAPs diet • Primary endpoint of “adequate IBS relief” • Secondary endpoints included reduction in abdominal pain, improved stool consistency,

Eswaran et al. Am J Gastroenterol Oct 2016.

NNT = 3.87

Is gluten content changing? • No clear increase in gluten content of wheat or breads despite extensive genetic modification over the years • Wheat genetics and agronomic practices may be contributors to increasing the “toxicity” of gluten…

Verdu et al. Am J Gastroenterol 2009.

Kasarda. J Agric Food Chem 2013.

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Potential RFs for gluten sensitivity • Wheat genetic modification • Environmental toxins • Gluten as a food additive • Hormonal influences • Genetics • Intestinal infections

Sapone et al. BMC Medicine 2012.

Cases

Take home messages

• Case 1

• Celiac Disease is common, but often does not present with “classic” features • Most patients respond well to a strict GFD • Emerging evidence suggests a subset of patients with functional GI symptoms may have gluten (and other) sensitivities

• Biopsies show villous atrophy • TTG negative after 6 months of GFD

• Case 2 • Duodenal biopsies normal • Advised to trial low FODMAPs diet for 4 weeks and consider elimination of dairy products as well

Questions?

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