Celiac disease - Revision history

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Rossdonaldson1: /* BackgroundFasano A, Catassi C. Celiac Disease. New England Journal of Medicine. 2012;367(25):2419-2426. doi:10.1056/nejmcp1113994.Parzanese I. Celiac disease: From pathophysiology to treatment. World Journal of Gastrointestinal Pathophysiology. 2017;8(2):27-38. doi:10.4291/wjgp.v8.i2.27.Freeman HJ. Adult Celiac Disease and Its Malignant Complications. Gut and Liver. 2009;3(4):237-246. doi:10.5009/gnl.2009.3.4.237. */

2024-02-28T23:34:09Z

BackgroundFasano A, Catassi C. Celiac Disease. New England Journal of Medicine. 2012;367(25):2419-2426. doi:10.1056/nejmcp1113994.Parzanese I. Celiac disease: From pathophysiology to treatment. World Journal of Gastrointestinal Pathophysiology. 2017;8(2):27-38. doi:10.4291/wjgp.v8.i2.27.Freeman HJ. Adult Celiac Disease and Its Malignant Complications. Gut and Liver. 2009;3(4):237-246. doi:10.5009/gnl.2009.3.4.237.

← Older revision		Revision as of 23:34, 28 February 2024
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	==Background<ref name="NEJM Celiac">Fasano A, Catassi C. Celiac Disease. New England Journal of Medicine. 2012;367(25):2419-2426. doi:10.1056/nejmcp1113994.</ref><ref name="Path">Parzanese I. Celiac disease: From pathophysiology to treatment. World Journal of Gastrointestinal Pathophysiology. 2017;8(2):27-38. doi:10.4291/wjgp.v8.i2.27.</ref><ref name="Complications">Freeman HJ. Adult Celiac Disease and Its Malignant Complications. Gut and Liver. 2009;3(4):237-246. doi:10.5009/gnl.2009.3.4.237.</ref>==		==Background<ref name="NEJM Celiac">Fasano A, Catassi C. Celiac Disease. New England Journal of Medicine. 2012;367(25):2419-2426. doi:10.1056/nejmcp1113994.</ref><ref name="Path">Parzanese I. Celiac disease: From pathophysiology to treatment. World Journal of Gastrointestinal Pathophysiology. 2017;8(2):27-38. doi:10.4291/wjgp.v8.i2.27.</ref><ref name="Complications">Freeman HJ. Adult Celiac Disease and Its Malignant Complications. Gut and Liver. 2009;3(4):237-246. doi:10.5009/gnl.2009.3.4.237.</ref>==
			[[File:Coeliac Disease.png\|thumb\|Schematic of the Marsh classification of upper jejunal pathology in coeliac disease.]]
	*Also known as “Celiac Sprue”		*Also known as “Celiac Sprue”
	*Affects 0.6 to 1.0% of worldwide population		*Affects 0.6 to 1.0% of worldwide population

Rossdonaldson1: /* Evaluation */

2024-02-28T23:31:45Z

Evaluation

← Older revision		Revision as of 23:31, 28 February 2024
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	==Evaluation<ref name="NEJM Celiac"></ref>==		==Evaluation<ref name="NEJM Celiac"></ref>==
			[[File:Celiac endo.png\|thumb\|Endoscopic still of duodenum of a person with celiac disease showing scalloping of folds and "cracked-mud" appearance to mucosa.]]
	*Rule out emergent causes of [[abdominal pain]] such as [[appendicitis]], [[small bowel obstruction]], [[bowel perforation]], etc.		*Rule out emergent causes of [[abdominal pain]] such as [[appendicitis]], [[small bowel obstruction]], [[bowel perforation]], etc.
	*Depending on presentation, chemistry panel and/or abdominal imaging may be appropriate in the emergency department setting		*Depending on presentation, chemistry panel and/or abdominal imaging may be appropriate in the emergency department setting

Kfarzam: /* Classic Features */

2022-08-20T06:18:25Z

Classic Features

← Older revision		Revision as of 06:18, 20 August 2022
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	*Chronic fatigue		*Chronic fatigue
	*Reduced bone mineral density		*Reduced bone mineral density
			*Vitamin D deficiency

	===Atypical Features===		===Atypical Features===

Elcatracho: /* Complications from untreated disease */

2021-02-23T18:57:50Z

Complications from untreated disease

← Older revision		Revision as of 18:57, 23 February 2021
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	*Adenocarcinoma of the jejunum		*Adenocarcinoma of the jejunum
	*Non-Hodgkin lymphoma		*Non-Hodgkin lymphoma
			*[[Vitamin deficiencies]]

	==Differential Diagnosis==		==Differential Diagnosis==

Elcatracho: /* Refectory Form */

2021-02-23T18:56:28Z

Refectory Form

← Older revision		Revision as of 18:56, 23 February 2021
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	*Found in patients with strong family history of disease, autoimmune disorders, chromosomal disorders ([[Down syndrome]])		*Found in patients with strong family history of disease, autoimmune disorders, chromosomal disorders ([[Down syndrome]])

	===~~Refectory~~ Form===		===Refractory Form===
	*Persistent or recurrent symptoms or villous atrophy despite gluten free diet for 12 months		*Persistent or recurrent symptoms or villous atrophy despite gluten free diet for 12 months

ClaireLewis at 01:11, 22 October 2020

2020-10-22T01:11:53Z

← Older revision		Revision as of 01:11, 22 October 2020
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	*1.5 to 2 times more prevalent in females than in males		*1.5 to 2 times more prevalent in females than in males
	*Gluten is found in wheat, rye, and barley		*Gluten is found in wheat, rye, and barley
	*Associated with strong family history, Type 1 DM, autoimmune thyroid ~~disorders~~ along with other autoimmune disorders, Turner’s syndrome, and [[~~Down’s~~ syndrome]]		*Associated with strong family history, Type 1 [[DM]], autoimmune [[thyroid disorder]]s along with other autoimmune disorders, Turner’s syndrome, and [[Down syndrome]]
	*Rotavirus infection in children increases risk of developing disease		*[[Rotavirus]] infection in children increases risk of developing disease
	*Breastfeeding reported to reduce risk by 50%		*Breastfeeding reported to reduce risk by 50%
	*MHC class II proteins HLA-DQ2 (90%) and HLA-DQ8 are expressed in almost all of patients affected by Celiac disease		*MHC class II proteins HLA-DQ2 (90%) and HLA-DQ8 are expressed in almost all of patients affected by Celiac disease
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	===Classic Features===		===Classic Features===
	*Classically presents around 6 to 18 months of age when foods containing gluten are introduced but can occur anytime		*Classically presents around 6 to 18 months of age when foods containing gluten are introduced but can occur anytime
	*Chronic diarrhea		*Chronic [[diarrhea]]
	*Weight loss		*Weight loss
	*Abdominal distension		*Abdominal distension
	*Iron deficiency with or without anemia		*Iron deficiency with or without [[anemia]]
	*Aphthous stomatitis		*[[Aphthous stomatitis]]
	*Short stature		*Short stature
	*High aminotransferase levels		*High aminotransferase levels
	*Chronic ~~Fatigue~~		*Chronic fatigue
	*Reduced bone mineral density		*Reduced bone mineral density

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	*Few or no gastrointestinal symptoms		*Few or no gastrointestinal symptoms
	*Older children or adults		*Older children or adults
	*Dermatitis herpetiformis		*[[Dermatitis herpetiformis]]
	*Gluten Ataxia		*Gluten Ataxia

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	*Patients have no symptoms		*Patients have no symptoms
	*Diagnosed based on serology of histology		*Diagnosed based on serology of histology
	*Found in patients with strong family history of disease, autoimmune disorders, chromosomal disorders ([[~~Down’s~~ syndrome]])		*Found in patients with strong family history of disease, autoimmune disorders, chromosomal disorders ([[Down syndrome]])

	===Refectory Form===		===Refectory Form===
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	*Severe diarrhea		*Severe diarrhea
	*Hypoproteinemia		*Hypoproteinemia
	*Metabolic and electrolyte ~~disturbances~~		*Metabolic and [[electrolyte disturbance]]s

	===Complications from untreated disease<ref name="NEJM Celiac"></ref><ref name="Path"></ref><ref name="Complications"></ref>===		===Complications from untreated disease<ref name="NEJM Celiac"></ref><ref name="Path"></ref><ref name="Complications"></ref>===
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	*Impaired splenic function		*Impaired splenic function
	*Infertility		*Infertility
	*Recurrent abortion		*Recurrent [[spontaneous abortion\|abortion]]
	*Ulcerative jejunoileitis		*Ulcerative jejunoileitis
	*Enteropathy-associated intestinal T-cell lymphoma		*Enteropathy-associated intestinal T-cell [[lymphoma]]
	*Adenocarcinoma of the jejunum		*Adenocarcinoma of the jejunum
	*Non-Hodgkin lymphoma		*Non-Hodgkin lymphoma
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	*[[Acute diarrhea]]		*[[Acute diarrhea]]
	* Chronic diarrhea		* Chronic diarrhea
	*[[Irritable ~~Bowel Syndrome~~]]		*[[Irritable bowel syndrome]]
	*[[Small intestinal bacterial overgrowth]]		*[[Small intestinal bacterial overgrowth]]
	*[[Lactose intolerance]]		*Lactose intolerance
	*[[Chronic ~~Pancreatitis~~]]		*[[Chronic pancreatitis]]
	*Microscopic colitis		*Microscopic colitis
	*[[Inflammatory ~~Bowel Disease~~]]		*[[Inflammatory bowel disease]]
	*Non-celiac gluten sensitivity (NCGS)		*Non-celiac gluten sensitivity (NCGS)
	*Wheat allergy		*Wheat allergy
	*Vitamin or mineral deficiency		*[[vitamin deficiencies\|Vitamin or mineral deficiency]]

	==Evaluation<ref name="NEJM Celiac"></ref>==		==Evaluation<ref name="NEJM Celiac"></ref>==
	*~~Important to rule~~ out emergent causes of abdominal pain such as [[appendicitis]], [[small bowel obstruction]], bowel perforation, etc.		*Rule out emergent causes of [[abdominal pain]] such as [[appendicitis]], [[small bowel obstruction]], [[bowel perforation]], etc.
	*Depending on presentation, chemistry panel and/or abdominal imaging may be appropriate in the emergency department setting		*Depending on presentation, chemistry panel and/or abdominal imaging may be appropriate in the emergency department setting

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	===Celiac Crisis<ref name="Crisis"></ref>===		===Celiac Crisis<ref name="Crisis"></ref>===
	*Fluid resuscitation		*[[Fluid resuscitation]]
	*Oral or IV steroids		*Oral or IV [[steroids]]
	*Supplemental nutrition		*Supplemental nutrition
	*Electrolyte repletion		*[[Electrolyte repletion]]
	*Gluten free diet		*Gluten free diet

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	==See Also==		==See Also==
	*[[Acute diarrhea]]		*[[Acute diarrhea]]
	*[[Irritable ~~Bowel Syndrome]]~~		*[[Irritable bowel syndrome]]
	*[[Lactose intolerance]]		*[[Inflammatory bowel disease]]
	*[[Inflammatory ~~Bowel Disease~~]]

	==References==		==References==
	<references/>		<references/>
			[[Category:GI]]

Rossdonaldson1: /* Pathophysiology */

2019-11-28T22:31:35Z

Pathophysiology

← Older revision		Revision as of 22:31, 28 November 2019
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	*MHC class II proteins HLA-DQ2 (90%) and HLA-DQ8 are expressed in almost all of patients affected by Celiac disease		*MHC class II proteins HLA-DQ2 (90%) and HLA-DQ8 are expressed in almost all of patients affected by Celiac disease

	==Pathophysiology<ref name="NEJM Celiac"></ref><ref name="Path"></ref>==		===Pathophysiology<ref name="NEJM Celiac"></ref><ref name="Path"></ref>===
	*Gluten triggers an immune mediated systemic disorder		*Gluten triggers an immune mediated systemic disorder
	*Can be weeks to years between gluten exposure and onset of symptoms		*Can be weeks to years between gluten exposure and onset of symptoms
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	*T-helper type 1 cells release IFN-gamma		*T-helper type 1 cells release IFN-gamma
	*T-helper type 2 cells promote conversion of B cells to plasma cells that produce anti-gliadin and anti-tissue-transglutaminase antibodies that are used in serologic testing		*T-helper type 2 cells promote conversion of B cells to plasma cells that produce anti-gliadin and anti-tissue-transglutaminase antibodies that are used in serologic testing
	*This process leads to celiac enteropathy with histological features such as decreased enterocyte height, crypt hyperplasia, villous atrophy, and increased intraepithelial T lymphocytes		*This process leads to celiac enteropathy with histological features such as decreased enterocyte height, crypt hyperplasia, villous atrophy, and increased intraepithelial T lymphocytes

	==Clinical Features==		==Clinical Features==

Mtjordan91: Created page with "==BackgroundFasano A, Catassi C. Celiac Disease. New England Journal of Medicine. 2012;367(25):2419-2426. doi:10.1056/nejmcp1113994.
2019-11-20T19:01:21Z

Created page with "==Background<ref name="NEJM Celiac">Fasano A, Catassi C. Celiac Disease. New England Journal of Medicine. 2012;367(25):2419-2426. doi:10.1056/nejmcp1113994.</ref><ref name="Pa..."

New page
==Background<ref name="NEJM Celiac">Fasano A, Catassi C. Celiac Disease. New England Journal of Medicine. 2012;367(25):2419-2426. doi:10.1056/nejmcp1113994.</ref><ref name="Path">Parzanese I. Celiac disease: From pathophysiology to treatment. World Journal of Gastrointestinal Pathophysiology. 2017;8(2):27-38. doi:10.4291/wjgp.v8.i2.27.</ref><ref name="Complications">Freeman HJ. Adult Celiac Disease and Its Malignant Complications. Gut and Liver. 2009;3(4):237-246. doi:10.5009/gnl.2009.3.4.237.</ref>==
Also known as “Celiac Sprue”
Affects 0.6 to 1.0% of worldwide population
Occurs in industrialized countries and developing countries among all ethnicities and races
Occurs in children and adults
1.5 to 2 times more prevalent in females than in males
Gluten is found in wheat, rye, and barley
Associated with strong family history, Type 1 DM, autoimmune thyroid disorders along with other autoimmune disorders, Turner’s syndrome, and [[Down’s syndrome]]
Rotavirus infection in children increases risk of developing disease
Breastfeeding reported to reduce risk by 50%
MHC class II proteins HLA-DQ2 (90%) and HLA-DQ8 are expressed in almost all of patients affected by Celiac disease

==Pathophysiology<ref name="NEJM Celiac"></ref><ref name="Path"></ref>==
Gluten triggers an immune mediated systemic disorder
Can be weeks to years between gluten exposure and onset of symptoms
*Gluten is mainly composed of prolamine and glutanin
**Prolamines (such as Gliadin found in wheat) interact with intestinal cells to cause breakdown of the inter-enterocyte tight junctions
Proposed that HLA-DQ2 and HLA-DQ8 present prolamines to antigen-specific CD4+ T lymphocytes in lamina propria of the small bowel
Once activated, CD4+ T cells release pro-inflammatory cytokines and activate T-helper cells
Proinflammatory cytokines such as IL-15 stimulate CD8+ T-lymphocytes
T-helper type 1 cells release IFN-gamma
T-helper type 2 cells promote conversion of B cells to plasma cells that produce anti-gliadin and anti-tissue-transglutaminase antibodies that are used in serologic testing
This process leads to celiac enteropathy with histological features such as decreased enterocyte height, crypt hyperplasia, villous atrophy, and increased intraepithelial T lymphocytes

==Clinical Features==

===Classic Features===
Classically presents around 6 to 18 months of age when foods containing gluten are introduced but can occur anytime
Chronic diarrhea
Weight loss
Abdominal distension
Iron deficiency with or without anemia
Aphthous stomatitis
Short stature
High aminotransferase levels
Chronic Fatigue
Reduced bone mineral density

===Atypical Features===
Few or no gastrointestinal symptoms
Older children or adults
Dermatitis herpetiformis
Gluten Ataxia

===Silent or Asymptomatic From===
Patients have no symptoms
Diagnosed based on serology of histology
Found in patients with strong family history of disease, autoimmune disorders, chromosomal disorders ([[Down’s syndrome]])

===Refectory Form===
Persistent or recurrent symptoms or villous atrophy despite gluten free diet for 12 months

===Celiac Crisis<ref name="Crisis">Jamma S, Rubio–Tapia A, Kelly CP, et al. Celiac Crisis Is a Rare but Serious Complication of Celiac Disease in Adults. Clinical Gastroenterology and Hepatology. 2010;8(7):587-590. doi:10.1016/j.cgh.2010.04.009.</ref>===
Life threatening
Often observed after a general immune stimulus such as surgery or infection
Mostly observed in children
Severe diarrhea
Hypoproteinemia
Metabolic and electrolyte disturbances

===Complications from untreated disease<ref name="NEJM Celiac"></ref><ref name="Path"></ref><ref name="Complications"></ref>===
Osteoporosis
Impaired splenic function
Infertility
Recurrent abortion
Ulcerative jejunoileitis
Enteropathy-associated intestinal T-cell lymphoma
Adenocarcinoma of the jejunum
Non-Hodgkin lymphoma

==Differential Diagnosis==
[[Acute diarrhea]]
Chronic diarrhea
[[Irritable Bowel Syndrome]]
[[Small intestinal bacterial overgrowth]]
[[Lactose intolerance]]
[[Chronic Pancreatitis]]
Microscopic colitis
[[Inflammatory Bowel Disease]]
Non-celiac gluten sensitivity (NCGS)
Wheat allergy
Vitamin or mineral deficiency

==Evaluation<ref name="NEJM Celiac"></ref>==
Important to rule out emergent causes of abdominal pain such as [[appendicitis]], [[small bowel obstruction]], bowel perforation, etc.
Depending on presentation, chemistry panel and/or abdominal imaging may be appropriate in the emergency department setting

{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Test'''
| align="center" style="background:#f0f0f0;"|'''Sensitivity'''
| align="center" style="background:#f0f0f0;"|'''Specificity'''
| align="center" style="background:#f0f0f0;"|'''Comments'''
|-
| IgA anti-tTG antibodies||>95||>95||Screening test
|-
| IgG anti-tTG antibodies||Variable||Variable||Screening test in patients with IgA deficiency
|-
| IgA antendomysial antibodies||>90||98.2||Useful if diagnosis unclear
|-
| IgG DGP||>90||>90||IgA deficiency and young patients
|-
| HLA DQ2 or HLA-DQ8||91||45||High NPV
|}

===Celiac Crisis<ref name="Crisis"></ref>===
History and physical
Assessment of volume status
CBC to look for evidence of iron deficiency anemia
CMP
VBG
Lactic acid

{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Signs of severe dehydration including: hemodynamic instability and/or orthostatic changes'''
|-
| Neurologic dysfunction
|-
| Renal dysfunction: creatinine >2.0 g/dL
|-
| Metabolic acidosis: pH <7.35
|-
| Hypoproteinemia (Albumin < 3.0 g/dL)
|-
| Abnormal electrolytes including: hyper/hyponatremia, hypocalcemia, hypokalemia or hypomagnesemia
|-
| Weight loss > 10 lbs
|}

==Management==

===Uncomplicated Celiac disease===
Avoid wheat, rye, barley which all contain gluten
Possible benefit to avoiding large amounts of Oats
IV fluids if necessary

===Celiac Crisis<ref name="Crisis"></ref>===
Fluid resuscitation
Oral or IV steroids
Supplemental nutrition
Electrolyte repletion
Gluten free diet

==Disposition==

===Uncomplicated Celiac disease===
Primary care follow up:
Serology, histology, and likely EGD
consultation with dietitian
treatment of nutritional deficiencies
referral to specialists
**serologic monitoring for recurrence

===Celiac Crisis===
Hospital admission

==See Also==
[[Acute diarrhea]]
[[Irritable Bowel Syndrome]]
[[Lactose intolerance]]
*[[Inflammatory Bowel Disease]]

==References==
<references/>