A young woman with fatigue

WHAT CAN CELIAC PATIENTS EAT?

4. Patients with celiac disease should avoid eating which of the following?

• Wheat
• Barley
• Rye
• Oats

Patients with celiac disease should follow a gluten-free diet and should initially eliminate all of these substances.

Some recent studies have suggested that pure oat powder can be tolerated without disease recurrence, although the long-term safety of oat consumption in patients with celiac disease is uncertain.⁹ It may be reasonable for patients to reintroduce oats when the disease is under control, especially since uncontaminated oats can be obtained from reliable retail or wholesale stores. The definitive diagnosis of celiac disease requires clinical suspicion, serologic tests, biopsy, and documented clinical and histologic improvement after a gluten-free diet is started.

All patients with celiac disease should receive dietary counseling and referral to a nutritionist who is experienced in the treatment of this disease. Because of the significant lifestyle and dietary changes involved in treating this disease, many patients may also benefit from participating in a celiac support group.

COMPLICATIONS OF CELIAC DISEASE

5. What are the complications of untreated celiac disease?

• Anemia
• Osteoporosis
• Intestinal lymphoma
• Infertility
• Neuropsychiatric symptoms
• Rash

All of the above are complications of untreated celiac disease and are often clinical features at presentation. Patients with celiac disease should be tested for anemia and nutritional deficiencies, including iron, folate, calcium, and vitamin D deficiency.

All patients should also undergo dual-energy x-ray absorptiometric scanning. Bone loss is thought to be related to vitamin D deficiency and secondary hyperparathyroidism, and may be partially reversed with a gluten-free diet.

Celiac disease is associated with hyposplenism, so pneumococcal vaccination should be considered. Celiac disease is also frequently associated with the rash of dermatitis herpetiformis, and diagnosis of this rash should prompt an evaluation for celiac disease.

Other associated conditions include Down syndrome, selective IgA deficiency, and other autoimmune diseases such as type 1 diabetes, thyroid disease, and liver disease.

WHAT HAPPENED TO OUR PATIENT?

Our patient tested positive for antiendomysial and antitransglutaminase antibodies and underwent small-bowel biopsy, which confirmed the diagnosis of celiac disease. She was started on a gluten-free diet, and within 2 weeks she noted an improvement in her symptoms of fatigue, GI upset, mood disorders, and difficulty with concentration. She met with a nutritionist who specializes in celiac disease and joined a celiac support group.

However, about 2 months later, her symptoms recurred. She again met with her nutritionist, who confirmed that she was adhering to a gluten-free and lactose-free diet. Even so, when she was tested again for antitransglutaminase antibodies, the titer was elevated. Stool cultures were obtained and were negative. She was started on a course of prednisone, and her symptoms resolved.

WHAT IF PATIENTS DO NOT RESPOND TO TREATMENT?

The most common cause of recurrent symptoms or nonresponse to treatment is noncompliance with the gluten-free diet or inadvertent ingestion of gluten. Patients who do not respond to treatment or who have a period of response but then relapse should be referred back to a nutritionist who specializes in celiac disease.

If a patient continues to have symptoms despite strict adherence to a gluten-free diet, other disorders should be considered, such as concomitant lactose intolerance, small-bowel bacterial overgrowth, pancreatic insufficiency, or irritable bowel syndrome. If these conditions are ruled out, patients can be considered for treatment with prednisone or other immunosuppressive agents. Patients with refractory symptoms are at higher risk of more severe complications of celiac disease, such as intestinal lymphoma, intestinal strictures, and collagenous colitis.

TAKE-HOME POINTS

• Celiac disease classically presents with symptoms of malabsorption, but nonclassic presentations are much more common.
• Celiac disease should be tested for in patients with or without symptoms of mal-absorption and other associated signs or symptoms including unexplained iron-deficiency anemia, infertility, short stature, delayed puberty, or elevated transaminases. Testing should be considered for symptomatic patients with type 1 diabetes or other autoimmune endocrinopathies, first- and second-degree relatives of patients with known disease, and those with certain chromosomal abnormalities.
• Heightened physician awareness is important in the diagnosis of celiac disease.
• Diagnosis depends on serologic testing, biopsy, and clinical improvement on a gluten-free diet.
• Treatment should consist of education about the disease, consultation with a nutritionist experienced in celiac disease, and lifelong adherence to a gluten-free diet. Referral to a celiac support group should be considered.
• Long-term follow-up should include heightened vigilance and awareness of the complications of celiac disease such as osteoporosis, vitamin D deficiency and other nutritional deficiencies, increased risk of malignancy, association with low birth-weight infants and preterm labor, and occurrence of autoimmune disorders.

Acknowledgments: I would like to extend a special thank you to Dr. Walter Henricks, Director, Center for Pathology Informatics, Pathology and Laboratory Medicine, Cleveland Clinic, for providing biopsy slides and interpretation. I would also like to extend thanks to Dr. Derek Abbott, Department of Pathology, Case Western University Hospitals, for his helpful criticisms.