Celiac disease diagnosis algorithm
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Transcript of Celiac disease diagnosis algorithm
Food Allergy &Food Intolerance
Diagnostic algorithm for Celiac Disease
Dr Ashok Rattan, MD, MAMSChief Operating Officer & Medical Director,
Star Metropolis Clinical LabDubai, Sharjah, Abu Dhabi
Diagnostic Algorithm for Celiac Disease
Food Allergy Vs Food intolerance
Definition of Food Allergy ?
Definition of Food AllergyFood allergy has no universally accepted
definition. The NIAID has suggestedthat food allergy be defined as
•“Adverse immune response that occurs reproducibly on exposure to a given food and is distinct from other adverse responses to food, such as, food intolerance, pharmacologic reactions or toxin mediated reactions”
ATOPYType 1Hypersensitivity
Signs & Symptoms of Food Allergy
Possible
Food allergy & “Intolerance”Type of Reaction Cause Food InvolvedAllergy Atophy, IgE mediated Eggs, Milk, Wheat, Fish,
Shellfish, Nut, Peanuts, Soya
Pharmacological Absorption of certain amines from food
Fermented food (cheese, red wine, sausages) fish
Enzyme defects Failure of normal enzymatic breakdown after absorption
Methanol, Lactose
Irritant Reflux Strong spices
Toxic Toxins Some shellfish, Mushroom, badly stored food
Chemicals MSD, Sulfites Chinese food, dry fruits
Celiac disease IgG to Gliadin, auto-immune
Wheat, Maize, Rye
Psychological Emotional reaction to food
Food proteins are recognized as “foreign”
Food specific IgG production and formation ofantigen/antibody complexes
Complexes are deposited in tissues and activateComplement
Complement and macrophages stimulate Inflammation
Delayed reaction and may last for days
Food Allergy
Food Intolerance
Signs & Symptoms of Food Intolerance
Class 0 No allergic reaction against tested food. No restriction is necessary.
Classes 1-2 Means that there is a low to moderate allergic reaction against tested food. These have to be avoided for 12
weeks.
Class 3 There is a major allergy type III against the tested foods. Strict avoidance for
6 months.
Class 4 There is a major allergy type III against the tested foods. Strict avoidance for
1 year.
30
Improvement of symptoms (%) after omitting allergenic food
Study, 2002-2008; evaluated by Mediveritas Institiute for Medical Studies, Munich
Celiac Disease
• Samuel Gee (1888) first described Celiac disease in “On the Coelic Affection”– Gluten sensitive entropathy– Nontropical sprue
• Aretaeus from Cappadocia (now Turkey) described similar malabsorption disorder in second century AD
Celiac disease “There is a kind of chronic indigestion
which is met with in persons of all ages, yet is especially apt to affect
children between one and five years old .
Signs of the disease are yielded by the fæces; being loose, not formed, but not watery; more bulky than the food taken would seem to account for; pale in colour, as if devoid of bile; yeasty, frothy, an appearance probably due to fermentation; stinking, stench often very great, the food having undergone putrefaction rather than concoction".
What is celiac disease ?
• Chronic inflammatory disease primary affecting small intestine
• Results from inflammatory response initiated by dietary gluten
• Inflammation leads to damage and atrophy of intestinal villae
Clinical featuresConsequence of intestinal inflammation & atrophy• Common clinical symptoms
– Abdominal pain– Diarrhea / vomiting nonspecific– Failure to thrive/malnutrition
• Comorbid conditions– Immunologic abnormalities
• Selective IgA deficiency
– Autoimmune endocrine disorders• Type 1 diabetes
– Dermatologic disorders
How common is it ?
World Wide Prevalence
Celiac Disease can present at ANY age to ANY specialty
Farrell RJ & Kelly CP: New Engl J Med 2002; 336: 180 - 188
Cause of celiac disease
• Willem K Diche recognized association between consumption of bread & relapsing diarrhoea
• WW 2: unconventional, non-cereal foods– Fruits, potatoes, banana, milk or meat
• After WW 2, symptoms reappeared
cereals
Deamidated Gliadin
Role of tTG in Celiac Disease
Endomycial antibodies
HLA & Celiac DiseaseUseful for ruling out celiac disease
Development of celiac disease
• Environmental component– Exposure to cereal grain proteins
• Wheat, barley, rye [gluten]
• Genetic component– Family members of individuals– HLA DQ 2 or HLA DQ 8
Auto Immune Reaction
Dermatitis Herpetiformis(Duhring’s disease)
Dermatitis Herpetiformis(Duhring’s disease)
• Chronic blistering skin condition• No virus involved• Autoantibodies present, gluten intolerance• Affects both male & females, 15 to 40 yrs of age• Intensively itchy, chronic papulo-vesicular rash• EMA positive (IFA): Ig A isotype• eTG (epidermal Transglumase) positive IgG / IgA• HLA DQ 2• Improvement when put on Gluten free diet
Ciliac Disease Histopathology
Small bowel mucosa in celiac disease showing subtotal villus atrophy.
Normal small bowel mucosa
Diagnosis
• Presumptive diagnosis– Positive serology– Intestinal biopsy with villous atrophy
• Definitive diagnosis– Resolution of clinical symptoms after initiation of
gluten free diet• Generally accompanied by conversion to negative
serology & reconstitution of villi
Laboratory Diagnosis of Celiac DiseaseMilestones
• Before 1960: based on clinical suspicion & biopsy
• 1982: Anti gliadin; Sensitivity: 70%; Specificity 70%
• 1985: Endomysial IFA; Sen: 70 – 90%; Specificity 100%
• 1997: Anti tTG by ELISA; Sen & Spec: 90 – 95%
• 2005: Anti deamidated Gliadin: Sen: 85%, Spec 90%
Serologic tests for celiac disease2014
• Tissue transglutaminase antibodies– IgA and IgG isotypes [ELISA]
• Deamidated gliadin antibodies– IgA and IgG isotypes [ELISA]
• Endomysial antobodies– IgA isotype only by IFA
Other investigations
• HLA DQ typing
• Small intestinal biopsy
• Total IgA
Test for selective IgA deficiency
Normal Total IgA
CD unlikely
HLA DQ2 & DQ8
Negative
S.I BiopsyPositive
Deamidated Gliadin IgA & IgGEMA IgA
+/+, +/-,-/+
CD unlikely
-/-
1.
IgA detectable but below RR
HLA DQ 2 & DQ 8
2.
Undetectable Total Ig A
• Selective IgA deficiency• Test for tTG • Test for Deamidated Gliadin
– Both for IgG isotype only
• If positive advice small intestinal biopsy
3.
Summary
• Total IgA– Identify individuals with selective IgA deficiency
• Anti TTG & Anti deamidated gliadin antibodies • IgA & IgG isotypes• Anti EMA IgA isotype by IFA
• Identify individuals with suspected celiac disease• Confirm with small intestine biopsy
– Specific antibodies may be absent if on gluten free diet
• HLA DQ 2 & HLA DQ 8– Negative results virtually excludes diagnosis of CD
Additional tests that need to be carried out
• CBC• TSH• LFT• Vitamins: D, A, E, K, Folate, B12• Calcium, Phosphate, Zinc• PTH• Iron studies• Bone Mineral Density Scan
Who should be tested ?Rubio Tapia R et al: Am J Gastro 2013: 108: 656 – 76
American Gastroenterology Society Recommendations
• Consider testing in symptomatic patients at high risk of– Autoimmune Hepatitis– Premature onset
osteoprosis– Primary Biliary cirrhosis– Unexplained increase in
liver transaminases– Unexplained iron
deficiency anemia
• Consider testing for CD when following are present:– Autoimmune Thyroid
disease– Cerebellar Ataxia– 1st & 2nd degree relatives – IBS– Peripheral neuropathies– Selective IgA deficiency– Type 1 diabetes– Turner & Down syndrome
Who should be tested ?ESPGHAN Guidelines for Celiac Disease 2012
European Society for pediatric gastroenterology, hepatology and nutrition • Group 1
– Children & adolescents with otherwise unexplained symptoms & signs of
• Chronic or intermittent diarrhea• Failure to thrive / Weight loss/
Stunted growth• Delayed puberty / Amenorrhea• Iron deficiency anemia• Nausea or vomiting• Abdominal pain, cramping or
distention• Chronic fatigue• Recurrent aphthous ulcer
• Group 2– Asymptomatic children &
adolescent with • Type 1 diabetes• Down syndrome• Autoimmune thyroid
disease• Turner syndrome• Selective IgA deficiency• Autoimmune liver disease• First degree relatives of
Celiac disease patients
A simple scoring system ESPGHAN Guidelines for Celiac Disease 2012
European Society for pediatric gastroenterology, hepatology and nutrition
Elements (Need Score of 4 for diagnosis) Score Symptoms: Malabsorption Other CD relevant symptoms or TIDM or 1st degree relative Asymptomatic
210
Serum antibodies EMA positivity and/or high positivity for anti tTG Low positivity for tTG or isolated anti DGP positivity Serology not performed Serology performed but all celiac specific antibodies negtive
210-1
HLA Full HLA DQ 2 or HLA 8 hetrodimer present No HLA performed or half DQ 2 present HLA neither DQ 2 or DQ 8
10-1
Histology Marsh 3b or 3c (subtotal villous atrophy, flat lesion) Marsh 2 or 3a (moderate decreased villous height) plus tTG antibodies Marsh 0 – 1 or no biopsy performed
210
One man’s alloo paratha maybe another man’s poison
CautionESPGHAN Guidelines for Celiac Disease 2012
European Society for pediatric gastroenterology, hepatology and nutrition
• A gluten free diet (GFD) should be introduced only after the completion of the diagnostic process and when a conclusive diagnosis has been made.
• Healthcare professionals should be advised that starting patients on a GFD, when CD has not been excluded or confirmed, may be detrimental.