In addition to these symptoms, there may also be skin issues resulting from contact with gluten-containing foods and products. This skin condition, called dermatitis herpetiformis (DH), is sometimes described as a celiac or a gluten rash. It is estimated that 15-25% of individuals with celiac disease experience DH.20


individuals there are no symptoms associated with the disease.


The mainstay of management is a strict gluten-free diet, which can help to both manage symptoms and to promote intestinal healing.


Gluten’s Role in CD: Consumption of wheat gluten and related proteins in wheat, rye and/or barley, act as environmental triggers, which cause an immune response in the small intestine that consequently leads to localized inammation and gastrointestinal cell death. Fouda MA, et al22


likened the CD population “to an iceberg, with only the tip visible over the waterline (the characteristically symptomatic patients), and the main body remaining underwater (the asymptomatic patients).” “Silent cases” or asymptomatic patients are dened by symptoms that include abnormal mucosal changes seen on biopsy, which return to normal on a gluten-free diet (GFD). “Latent CD” patients are described as “those with a normal jejunal biopsy but who test positive for immunoglobulin (Ig) A, endomysial antibody (EMA), and/or IgA-tissue transglutaminase (tTG).”26


Endomysial antibodies are antibodies specic to Celiac disease. Their presence results in intestinal swelling and, if undetected, they may result in damage to the intestinal walls.


The primary test utilized in the screening for Celiac disease is the blood test for human tissue transglutaminase antibody (hTTG), IgA class. It is also the preferred test and is considered “the most sensitive and specic blood test for celiac disease”, according to the 2013 guidelines as specied by the American College of Gastroenter- ology and the American Gastroenterology Association for the detection of Celiac disease in those over the age of two years.27


recognized the analogy by Ferguson et al,25 who However, for many


undiagnosed.30,31


demonstrated “that bone mineral density does improve in adult patients who adhere to a GFD.”32,33,34,35,36,37,38


Diagnosis: The Mayo Clinic has published a ow chart entitled “Celiac Disease Diagnostic Testing Al- gorithm,” to aid in proper diagnosis of CD.39


transglutaminase (TTG) antibody test is recommended for diagnosis. A “potential” CD diagnosis consists of an abnormally high TTG antibody level on at least two separate occasions, which serves to rule out a false positive on a single test.


Currently, Celiac disease is more commonly diagnosed in adulthood rather than in childhood, with as many as 50% of adults diagnosed at age 50 or older.40 to Goddard and Gillett,41


and Williams syndrome.”46


in those diagnosed with specic diseases, including Type 1 diabetes,42


Down’s syndrome,43


“the prevalence is even higher Turner syndrome,44,45


complication of untreated celiac disease.48


Osteoporosis, a Complication of CD: The prevalence of osteoporosis and osteopenia in patients newly diagnosed with Celiac disease is anticipated to exceed 75%. In adult patients with CD, others have been estimated that approximately one-third have osteoporosis, one-third have osteopenia, and one-third have normal bone mineral density (BMD).47


osteopenia is also a well-documented consequence of the disease, which is demonstrated to recover with adherence to a gluten-free diet.49


osteoporosis may also be correlated to undiagnosed CD1 Bianchi and Bardella have proposed two main mechanisms for this pathogenic process, 1) intestinal malabsorption and 2) the presence of chronic inammation.50 CD is likely an additional factor.


Chronic inammation and malabsorption in CD can cause alterations in bone metabolism and bone mineral loss in both children and adults.50


Fractures associated with Undiagnosed


This test is also used to monitor those with celiac disease, and to help evaluate the effectiveness of treatment, as once gluten is removed from the diet, antibody levels should decline. In testing the “sensitivities and specicities are higher than 85% and 97% for the endomysial antibody, and 90% and 97% for hTTG,”2 making both test good diagnostic tools.


The exact link between Celiac disease and excess bone loss remains unknown, however, there are several potential reasons for the relationship. These include:28  Vitamin D deciency  Calcium malabsorption  Magnesium malabsorption  Chronic inammation


diagnosed after the age of fty. However, according to population-based studies, 50-90% of those with CD remain


36


Statistics. A majority of the diagnosed cases of CD occur after the age of fty.29


In fact, fty percent of adults are


The small intestine is the site of absorption for many im- portant nutrients, including calcium. Calcium is essential for building and maintaining healthy bones. In those with celiac disease, even with adequate calcium consumption, deciency exists, due primarily to malabsorption issues. As a consequence, low bone density is common in children and adults in both newly diagnosed and untreated celiac disease.51


Lucendo AJ, et al have estimated that celiac patients have a 40% increased risk of bone fractures, compared to that of a matched non-affected population.52


According to Mki M, el al, “in symptomatic patients osteopenia is a well-documented consequence of coeliac disease, which is known to recover on gluten-free diet.”53 Professionals recommend that patients with celiac disease be evaluated and monitored for both calcium and vitamin D deciencies. Without supplementation, omitting dairy products from the diet can create a risk for decreased bone density. With adherence to a strict gluten-free diet, bone mineral density and vitamin D deciencies have been found to improve but still may require supplementation to correct deciencies.54


Osteoporosis is a well-documented Likewise,


According The tissue


Similarly, longitudinal studies have


THE ORIGINAL INTERNIST MARCH 2017 (Continued on next page)


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