NORTH TEXAS GLUTEN INTOLERANCE SUPPORT GROUP
U.S. Celiac Prevalence Figures: 1% (1 in 133 healthy
Americans or 2.2 million people are living with Celiac
Disease and 97% don’t know it)!
NIH CONSENSUS PANEL
FINDS CELIAC DISEASE UNDER- DIAGNOSED:
Panel Recommends Six
Key Strategies for Disease Management
We want to update you about Celiac Disease and
Dermatitis Herpetiformis. We hope you will refer newly
diagnosed celiacs and people with dermatitis
herpetiformis immediately to a dietitian familiar with
the gluten free diet and to our group. I have been
attending celiac educational conferences for many
years. We who live with the gluten-free diet every day
have all the tools to help newly-diagnosed celiacs.
Dr. Ciaran Kelly, gastroenterologist in Boston
says that it is important for doctors to know that
Celiac Disease is common and easily diagnosed. There is
need for more education of physicians and dietitians
regarding diagnosing and treatment of CD. (See III and
IV on other pages.)
CD is considered to be the most underdiagnosed
common disease today and the average length of time
between onset of symptoms and confirmation of CD
diagnosis is 11 years! This delay in diagnosis may be
due to several factors:
Most MD's and RD's were taught
that Celiac Disease was a rare disease and that patients
presented only with classical gastrointestinal symptoms.
(It is now known that many patients do not present with
any GI symptoms or are asymptomatic in spite of gluten
sensitivity). As a result, patients are not routinely
tested for CD. Some of the symptoms and complications
of CD are listed on our chapter website. Irritable Bowel
Syndrome (IBS)-type symptoms and severe fatigue can be
signs of CD. However, now patients present with more
extraintestinal symptoms. THINK CELIAC DISEASE high on
your list of possible diagnoses!
small bowel endoscopy with biopsy is still considered
the gold standard for diagnosis. However, serologic
tests are useful first screening tools when
studying those with an increased risk for the disease or
when CD is suspected. It is essential that all these
tests be done while the patient is on a gluten-
containing diet. However, keep in mind that the blood
tests tend to pick up medium- to full-blown Celiac
Disease. Certain “national” laboratories that have
convened together about standards have more experience
and reliability than some local labs.
The anti-gliadin antibody(AGA) serological test is often
used but it is not as sensitive and specific as the EMA
and tTG antibody tests. However, five tests
should be done to screen for Celiac Disease; i.e., the
IgA anti-gliadin antibody, IgG anti-gliadin antibody,
anti-endomysial (EMA) and tissue transglutaminase (tTG),
as well as the Serum IgA to test whether the patient is
Endoscopy samples may miss active patches of the disease
in the specific samples that are drawn. Therefore,
multiple samples (8-20 total) are recommended from both
the first and second portion of the small intestine.
Pathologists may not recognize early features of CD and
only report a positive diagnosis with total villous
atophy. (Many CD patients present with various degrees
of partial villous atrophy.)
Herpetiformis is the skin manifestation of Celiac
Disease. To diagnose, one takes a tissue sample next
to a lesion for direct immunoflourescence. While
Dapsone is often used to control the itching, the
cornerstone of therapy is a gluten-free diet. If
a DH patient has been diagnosed correctly with an
immunoflourescence biopsy, that person need not have
blood screening or endoscopic procedure because they
automatically have Celiac Disease. Gluten ingestion
causes the skin manifestation.
Celiac Disease is genetic and autoimmune. Therefore, CD
can present in family members or in later generations.
People with conditions such as Type 1 Diabetes,
Addison’s Disease, thyroiditis, Sjogren’s syndrome,
Rheumatoid arthritis, Lupus, etc., are at risk to
develop Celiac Disease. In addition, a variety of
neurophychiatric conditions such as depression, anxiety,
peripheral neuropathy, ataxia, epilepsy with or without
cerebral calcifications and migraine headaches have been
reported in individuals with CD. People with such
extraintestinal presentations as unexplained short
stature, delayed puberty, infertility, recurrent fetal
loss, osteoporosis, vitamin deficiencies, fatigue,
protein calorie malnutrition are more at risk to develop
bone density test is important for all celiacs, both at
the time of diagnosis and follow up, because of the
possibility of the patient not absorbing enough
calcium and vitamin D for years.
To put Celiac Disease in perspective: Type 1 Diabetes
affects 1,177,500 people; 6% of those will also have
CD. 610,000 women in the U.S. experience unexplained
infertility; 6% of these women might never learn that CD
is the cause. 350,000 people in the U.S. are living
with Down Syndrome; 12% of them also have CD. The
number of people with CD in the U.S. is roughly equal to
the number of people living in the state of Nevada. The
incidence of autoimmune diseases in the general U.S.
population is 3.5%. Research has shown that those
diagnosed with Celiac Disease between 2-4 years of age
had a 10.5% chance of developing another autoimmune
disorder and the chances increase the older patients are
diagnosed, up to 34% over the age of 20.
Source: Duration of exposure to gluten and risk for
autoimmune disorders in patients with celiac disease.
SIGEP Study Group for Autoimmune Disorders in Celiac
Disease. Ventura A. et.at. Gastroenterology 1999 Aug;
Certain populations have an increased prevalence of CD.
Among more groups with increased risk are those with
diabetes mellitus, Down syndrome, Turner syndrome,
Williams syndrome, selective IgA deficiency, and
autoimmune disorders. Prevalence in people with
related symptoms: 1 in 56; in people with first degree
relatives: 1 in 22; in people with second-degree
relatives who are celiac: 1 in 39; estimated for
prevalence for African, Hispanic and Asian-Americans: 1
in 236. The average length of time it takes for a
symptomatic person to be diagnosed with celiac disease
in the U.S. is eleven years; this delay
dramatically increases an individual’s risk of
developing additional auto-immune disorders,
neurological problems, osteoporosis and even cancer.
Source: Characteristics of adult celiac disease in the
USA: results of national survey. Green, P.H. et.al.
American Journal of Gastroenterology, 2001.
We ask that you refer your newly diagnosed celiac
patients to our support group, North Texas GIG and our
website, www.northtexasgig.com. Newly-diagnosed celiacs
can use this site as an introduction to the
disease and gluten-free diet issues. It is vitally
important that patients get tested correctly and not try
out a gluten-free diet themselves, and thus possibly
compromise a future testing process. You can refer your
new patients to this site to get them started on the
gluten-free diet. Again, please refer new celiacs to us
to participate in our meetings. The key to successful
journey to health is continuing education about the
disease and dietary issues.
Our chapter newsletter, The North Texas GIG
Communicator, gives medical information about
Celiac Disease and Dermatitis Herpetiformis, dietary
coping strategies, gluten-free product information,
articles by celiacs themselves and gluten-free recipes.
We hope you will refer new celiac patients to our
support group. We give supplemental information to that
of our parent national organization, GIG, Gluten
Intolerance Group, www.gluten.net. We conduct a
separate class, called Celiac 101, for any
newly-diagnosed celiac who comes to our meetings giving
them a comprehensive introduction to the gluten free
living lifestyle. We also conduct a meeting for all the
"well seasonsed" celiacs updating them on any new
information regarding their particular health issues.
Please support us in our endeavors.
Celiac Disease can ultimately be a very satisfying
diagnosis, both for the patient and the physician. It
is readily treatable, requires no dangerous medications
and can dramatically improve the patient’s health, sense
of well being, and quality of life.
Betty Barfield, President
North Texas Gluten Intolerance Group
Locally, the North Texas Gluten Intolerance Support
www.northtexasgig.com assists people who have been
diagnosed with Celiac Disease (gluten intolerance),
people who are sensitive to wheat, people with
Dermatitis Herpetiformis, and families with autistic
children who need a casein-free, gluten-free diet. The
North Texas group is a chapter of the national Gluten
Intolerance Group of Seattle, WA. We meet on the first
Saturday of the month at Richland Hills Church of Christ,
6300 NE Loop 820, N. Richland Hills, TX 76180. A free Celiac 101 class is held
at 9AM – 12PM for the newly diagnosed and our regular
support group meeting starts at 10AM – 12PM.
Questions: contact Betty Barfield, 817-967-2804 or
NIH CONSENSUS PANEL FINDS CELIAC DISEASE
UNDER-DIAGNOSED: Panel Recommends Six Key Strategies
for Disease Management
The National Institutes of Health (NIH) Consensus
Development Conference on Celiac Disease was held in
Bethesda, MD, on June 28-30. 2004. The full text of the
panel's draft consensus statement is available at
The archived videocast of the conference sessions is
SUMMARY OF HIGHLIGHTS
Celiac Disease has many names: celiac sprue,
gluten-sensitive enteropathy, non-tropical sprue, gluten
intolerance, in addition to a host of other names. It
is thought to result from activation of both a
cell-mediated (T-cell) and humoral (B-cell) immune
response upon exposure to gluten (prolamins and
glutenins) of wheat, barley and rye. Celiac disease is
considerably under diagnosed, according to an
independent consensus panel convened in June 2004 by the
National Institutes of Health (NIH).
The panel, charged with assessing all of the
available scientific evidence on celiac disease
announced its recommendations for the appropriate
diagnosis and management of this disease, which was
previously believed to be rare. Celiac disease may
affect 3 million Americans. The disease is present in
0.5 to I % of the U.S. population, ten times higher than
"We know that celiac disease is caused by an
immune response to the gluten in certain common grains,
so we have a very effective treatment - a gluten-free
diet - but if physicians don't recognize when to test
for the disease, patients are going to suffer
needlessly", said Charles Elson, M.D. of the University
of Alabama at Birmingham, and chair of the consensus
panel. He added, "Because the disease has been thought
to be rare, testing for it may not occur to many
hope that this conference will help to increase
The panel found that increasing physician
awareness of the various manifestations of celiac
disease and appropriate use of available testing
strategies may lead to earlier diagnosis and better
outcomes for celiac patients
How Is Celiac Disease Diagnosed?
diagnostic tests need to be performed while the patient
is on a gluten-containing diet. The first step in
pursuing a diagnosis of celiac disease is a serologic
test. Based on very high sensitivities and
specificities, the best available attests are the IgA
antihuman tissue transglutaminase (tTG) and IgA
endomysial antibody immunoflourescence (EMA) tests that
appear to have equivalent diagnostic accuracy.
Biopsies of the proximal small bowel are indicated
in individuals with a positive celiac disease antibody
test, except those with biopsy-proven dermatitis
herpetiformis. Multiple biopsies should be obtained
because the histologic changes may be focal. Biopsies
should be obtained from the second portion of the
duodenum or beyond. The pathology report should specify
the degree of crypt hyperplasia and villous atrophy as
well as assess the number of intraepithelial
lymphocytes. Some degree of villous atrophy is
considered necessary to confirm a diagnosis of celiac
disease. Standardization of the pathology reports in
celiac disease is desirable, using published criteria
such as modified Marsh criteria (1999). Communication
between the pathologist and the individual’s physician
is encouraged to help correlate the biopsy findings with
laboratory results and clinical features. With
concordant positive serology and biopsy results, a
presumptive diagnosis of CD can be made. Definitive
diagnosis is confirmed when symptoms resolve
subsequently with a gluten-free diet. A demonstration
of normalized histology following a GF diet is no longer
required for a definitive diagnosis of CD.
How Prevalent is Celiac Disease?
Population-based studies in the U.S. suggest that the
prevalence of CD is in the range 0.5 to 1.0 percent,
similar to estimates in Europe or 1 in 133 healthy
Americans. These prevalence figures include both
symptomatic and asymptomatic individuals.
What are the Manifestations and Long-term Consequences
of Celiac Disease?
Celiac disease traditionally has been defined as a
gastrointestinal malabsorptive disorder that can present
early in childhood after the introduction of gluten. It
is now recognized, however, that the clinical
manifestations are highly variable, may present at any
age and involve multiple organ systems. Prolonged
delays in diagnosis are common.
Typical gastrointestinal manifestations may
include diarrhea, weight loss, failure to grow,
vomiting, abdominal pain, bloating and distension,
anorexia, and constipation. The presence of obesity
does not exclude the diagnosis. It is very common for
CD to present with extraintestinal manifestations,
sometimes with little or no gastrointestinal symptoms.
A distinctive example is dermatitis herpetiformis, an
intensely pruritic rash on the extensor surfaces of the
extremities. Iron deficiency anemia is common and may
be the only presenting sign. Other extraintestinal
presentations are unexplained short stature, delayed
puberty, infertility, recurrent fetal loss,
osteoporosis, vitamin deficiencies, fatigue, protein
calorie malnutrition, recurrent aphthous stomatitis,
elevated transaminases, and dental enamel hypoplasia.
CD may also be associated with autoimmune conditions
such as thyroiditis, diabetes type 1, Addition’s
disease, Sjogren’s syndrome, Rheumatoid arthritis, etc.
In addition, a variety of neurophychiatric conditions
such as depression, anxiety, peripheral neuropathy,
ataxia, epilepsy with or without cerebral
calcifications, and migraine headaches have been
reported in individuals with CD.
Based on the research presented it seems that CD
represents a spectrum of clinical features and
presentations. Although Classical CD (villous atrophy
and intestinal malabsorption) is most commonly
described, it appears that most patients have atypical
CD which is fully developed gluten-induced villous
atrophy found in the setting of another presentation
such as iron deficiency, Osteoporosis, short stature, or
infertility. The silent CD in asymptomatic patients is
found either by serologic screening or perhaps an
endoscopy for another reason. Another form is the
latent CD, which is characterized by a previous
diagnosis that responded to a GF diet and retained a
normal mucosal histology upon a later introduction of
gluten, or can represent patients with normal mucosa but
develop gluten sensitive enteropathy.
of Celiac Disease
Complications of CD typically occur after many years of
disease and usually are observed in adults. Refractory
CD refers to persistence of symptoms and intestinal
inflammation despite a gluten-free diet. This may occur
in the context of ulcerative jejunity, or it may be an
early manifestation of intestinal lymphoma. Some
evidence suggests that a GF diet may reduce lymphoma
Who Should Be Tested for CD?
Individuals with GI symptoms, including chronic
diarrhea, malabsorption, weight loss, and abdominal
distension, should be tested for CD. Because CD is a
multisystem disorder. Physicians should be aware of
other conditions for which CD testing should be
considered. People with the conditions mentioned in the
paragraph ”Manifestations and Long-Term Consequences”
above are more at risk to develop CD. In addition,
other conditions for which CD testing may be considered
include irritable bowel syndrome, osteopenia/osteoporosis,
etc. At this time, there are insufficient data to
recommend screening of the general population for celiac
What is the Management of Celiac Disease?
Treatment for CD should begin only after a complete
diagnostic evaluation including serology and biopsy.
The management of celiac disease is a gluten-free diet
for life, excluding wheat, barley and rye. The
practical inclusion of oats in a GF diet is limited by
potential contamination with gluten during processing.
Based on its assessment of an extensive collection
of medical literature and expert presentations, the
panel identified six elements essential to treating
celiac disease once it is diagnosed:
- Consultation with a skilled dietitian,
- Education about the disease,
- Lifelong adherence to a gluten-free diet,
- Identification and treatment of nutritional
- Access to an advocacy group, and
- Continuous long-term follow-up.
Are the Recommendations For Future Research on Celiac
Disease and Related Conditions?
list of research studies recommended in the NIH Draft
Conclusions and Recommendations
Celiac disease is an immune-mediated intestinal disorder
with protean manifestations. CD is common, affecting
0.5 to 1.0 percent of the general population of the
U.S., but is greatly under diagnosed. There are now
specific and sensitive serologic tests available to aid
in diagnosis that need to be more widely applied. The
treatment of CD remains a lifelong gluten-free diet,
which results in remission for most individuals. The
classic presentation of diarrhea and malabsorption is
less common, and atypical and silent presentations are
increasing. Most individuals are being seen by primary
care providers and a broad range of specialists.
Therefore, heightened awareness of this disease is
imperative. Education of physicians, registered
dietitians, and other health providers is needed.
The Panel recommended the following:
Education of physicians, dietitians, nurses, and the
public about CD by a trans-NIH initiative, to be led by
the NIDDK in association with the Centers for Disease
Control and Prevention. Standardization of serologic
tests and pathologic criteria for the diagnosis of CD.
Adoption of a standard definition of a gluten-free diet
based on objective evidence such as that being developed
by the American Dietetic Association.
Development of an adequate testing procedure for gluten
in foods and definition of standards for GF foods in the
U.S. to lay the foundation for national food labeling.
Formation of one federation of CD societies, CD interest
groups, individuals with CD and their families,
physicians, dietitians, and other health care providers
for the advancement of education, research, and advocacy
for individuals with celiac disease.
information can be obtained by visiting the website
listed at the beginning of this summary.
UNIV. OF MARYLAND CENTER FOR CELIAC RESEARCH
The Center is co-directed by Alessio Fasano, MD.; the
Center is engaged in clinical care, diagnostic support,
education, and clinical and science research.
CELIAC DISEASE CENTER AT COLUMBIA UNIVERSITY
The Center is directed by Peter Green, MD., and devoted
to patient care and physician and patient education and
UNIVERSITY OF CHICAGO CELIAC DISEASE PROGRAM
Hotline Phone: 773/702-7593.
Center is directed by Stefano Guandalini, MD., and
dedicated to patient care services, research activities,
medical education and public awareness.
GLUTEN INTOLERANCE GROUP (GIG),
www.gluten.net ; Phone: 206/2476-6652.
booklet, Diabetes, Celiac Disease and Me,
available through website. Many educational pamphlets,
including “Quick Start Diet Guide for Celiac Disease.”
CELIAC DISEASE FOUNDATION,
Studio City, CA
www.celiac.org ; 818/990-CELIAC. Cooperated on
“Quick Start Diet Guide for Celiac Disease.”
NORTH TEXAS GIG,
serving Tarrant County, TX and surrounding area
www.northtexasgig.com. Betty Barfield, President,
GLUTEN-FREE DIET: A COMPREHENSIVE RESOURCE GUIDE
Shelley Case, R.D. See her website at
www.glutenfreediet.ca to read the reviews, table of
contents and how to order.
firstname.lastname@example.org; Phone: (306) 536-7716. Get
free copy of “Going Gluten-Free: A Primer for
Clinicians” on this website.
WHEAT-FREE, WORRY-FREE, THE ART OF HAPPY, HEALTHY,
Danna Korn, Hay House, pub.
III. EDUCATIONAL CAMPAIGN – NEW PHYSICIAN MATERIALS
Children’s Digestive Health and Nutrition Foundation (CDHNF)
with the North American Society for Pediatric
Gastroenterology, Hepatology and Nutrition (NASPGHAN)
announced the launch of a new educational campaign on
Celiac Disease, one of the most common genetic digestive
conditions possibly affecting as many as three million
Americans (up to 1 percent). Since it has been proven
that early detection and intervention can prevent
long-term consequences, CDHNF and NASPGHAN are focusing
on accurate and timely diagnosis and treatment in
“We plan to raise greater awareness about celiac
disease and urge physicians to add it to their screening
checklist,” said Alessio Fasano, M.D., chair of the
CDHNF Celiac Disease Campaign, NIH Consensus speaker and
director of the Mucosal Biology Research Center for the
University of Maryland School of Medicine Center for
Celiac Research. “We now have the information we need on
how to diagnose and treat this disease and we need to
start applying that knowledge into practice.”
To help spread the word, the campaign will
include physician materials such as a celiac disease
physician CME slide set, a nationwide Grand Rounds
program, and a soon-to-be released NASPGHAN “Clinical
Practice Guideline on the Evaluation and Management of
Celiac Disease in Children,” in the fall of 2004. In
addition, a new web site,
http://www.celiachealth.org will provide
resources for the medical professional community and the
FOOD ALLERGEN LABELING and CONSUMER PROTECTION ACT
President Bush signed the Food Allergen
Labeling and Consumer Protection Act (S. 741) into
law on August 2, 2004! (Enactment began Jan.
bill amends the Federal Food, Drug, and Cosmetic Act to
require a food that contains, or is derived from, a
major food allergen to indicate that information on its
label. Defines "major food allergen" as any of the
following top 8 allergens: milk, eggs, fish,
crustacea, tree nuts, peanuts, wheat and soybeans.
Additionally, it provides that the labeling requirement
must be met by stating the common or usual name of the
food allergen in the list of ingredients or by other
methods allowed by the Secretary. It requires allergens
in flavoring, coloring, or incidental additives to also
be labeled in accordance with these requirements. Some
manufacturers are using such labeling at the present
When this legislation goes into affect in
January 2006, it will enable celiacs and people with
other food sensitivities to be able to read food labels
more effectively. However, this bill does not affect
medicines. Pharmaceutical companies, physicians, and
druggists need to partner together to help inform the
public about allergens in their products, both
over-the-counter and prescription. We cannot judge from
the package labels concerning gluten in most meds at the
INTERESTING SAMPLE of CELIAC RESEARCH ABSTRACTS
More and more celiac research is being done!
CELIAC DISEASE. CME UPDATE FOR FAMILY PHYSICIANS
Fam Physician. 2004 May;50:719-25. Devlin SM, Andrews
CN, Beck PL.; Division of Gastroenterology, Faculty of
Medicine, University of Calgary, Alberta.
OBJECTIVE: To review current understanding of the
epidemiology, pathophysiology, diagnosis, and management
of celiac disease. QUALITY OF EVIDENCE: Few recent
randomized controlled trials (level I evidence) have
studied treatments for celiac disease. There are recent
comparative studies (level II evidence) and there is
well established consensus (level III evidence) on
diagnosis and treatment of celiac disease.
MESSAGE: Celiac disease is an immune-mediated small
bowel enteropathy caused by exposure to wheat gluten
protein. The disease can be insidious and often presents
with only subtle extraintestinal manifestations in a
variety of organ systems. Recent epidemiologic surveys
suggest celiac disease is much more common in North
America than previously thought. Advances in immunology
and screening have made diagnosis more reliable than in
the past. Removing gluten from the diet is effective in
CONCLUSION: Celiac disease manifests subtly and is an
easy diagnosis to miss. Good laboratory screening tests
and effective treatment are available. Family
practitioners should consider celiac disease in patients
who present with confounding symptoms.
Gynecologic and obstetric findings related to
nutritional status and adherence to a gluten-free diet
in Brazilian patients with celiac disease.
J Clin Gastroenterol. 2004 Aug;38(7):567-74. -
Kotze LM.; Gastroenterology Service, Cajuru Hospital,
Pontifical Catholic University of Parana, Curitiba,
This study shows a broad analysis of gynaecological and
obstetrical disturbances in patients with celiac disease
in relation to their nutritional status and adherence to
a gluten-free diet. The significant findings were
observed as follow: adult celiac patients, irrespective
of the nutritional status, were younger than controls,
presented delayed menarche, secondary amenorrhea, a
higher percentage of spontaneous abortions, anemia and
hypoalbuminemia. No differences were observed regarding
the number of pregnancies, age at menopause and duration
of the reproductive period. After treatment, patients
presented with normal pregnancies and one patient
presented spontaneous abortion. The adolescents who were
not adherent to gluten-free diet presented delayed
menarche and secondary amenorrhea. In conclusion, gluten
per se could explain the disturbances and malnutrition
would worsen the disease in a consequent vicious cycle.
Therefore, celiac disease should be included in the
screening of reproductive disorders.
Mental disorders in adolescents with celiac disease.
Psychosomatics. 2004 Jul-Aug;45(4):325-35.
Pynnonen PA, Isometsa ET, Aronen ET, Verkasalo MA,
Savilahti E, Aalberg VA. - Hospital for Children and
Adolescents, Helsinki University Central Hospital,
A high prevalence of depressive symptoms, hypothetically
related to serotonergic dysfunction, has been reported
among adults with celiac disease. The authors used
semistructured psychiatric interviews and symptom
measurement scales to study mental disorders in 29
adolescents with celiac disease and 29 matched
comparison subjects. Relative to the comparison
subjects, the celiac disease patients had significantly
higher lifetime prevalences of major depressive disorder
(31% versus 7%) and disruptive behavior disorders (28%
versus 3%). In most cases these disorders preceded the
diagnosis of celiac disease and its treatment with a
gluten-free diet. The prevalence of current mental
disorders was similar in both groups. Celiac disease in
adolescents is associated with an increased prevalence
of depressive and disruptive behavioral disorders,
particularly in the phase before diet treatment.
Seronegative celiac disease: increased prevalence with
lesser degrees of villous atrophy.
Dig Dis Sci. 2004 Apr;49(4):546-50. Abrams JA,
Diamond B, Rotterdam H, Green PH.; Department of
Medicine, Columbia University College of Physicians and
Surgeons, New York, New York, USA.
Our aim was to assess differences in the sensitivities
of serologic tests used for the diagnosis of celiac
disease among patients with varying degrees of villous
atrophy. Among 115 adults with biopsy-proven celiac
disease who fulfilled strict criteria, including
serologic testing at the time of diagnosis and response
to a gluten-free diet, 71% had total villous atrophy and
29% partial villous atrophy. Endomysial antibody was
positive in 77% of those with total villous atrophy,
compared to 33% with partial villous atrophy (P <
0.001). There was no difference in sensitivity when the
type of presentation (classical vs. silent) was
compared. Endomysial antibody-positive and negative
patients did not differ with respect to age at
diagnosis, duration of symptoms, mode of presentation,
or family history of celiac disease. All anti-tissue
transglutaminase-positive patients had TVA on biopsy.
Seronegative celiac disease occurs. Endomysial antibody
positivity correlates with more severe villous atrophy
and not mode of presentation of celiac disease.
Serologic tests, in clinical practice, lack the
sensitivity reported in the literature.
Adult celiac disease and the severe "flat" small bowel
Dig Dis Sci. 2004 Apr;49(4):535-45. Freeman HJ.
Department of Medicine (Gastroenterology), University of
British Columbia, Vancouver, BC, Canada.
Classification of architectural changes in the small
intestinal biopsy may be clinically useful to define the
cause of diarrhea or suspected malabsorption, especially
in adults. Pathologic changes may include severe (flat)
or variably severe (mild or moderate) abnormalities. For
some disorders, small bowel biopsy findings may be very
distinctive and lead to a specific diagnosis. For
others, like adult celiac disease, biopsy changes are
less specific. Indeed, it is becoming increasingly
appreciated that several conditions can produce similar
histopathologic changes. Serological assays, including
endomysial antibodies and tissue transglutaminase
antibodies, may be very useful tools for screening and
case finding in clinical practice. However,
demonstration of characteristic changes in the small
intestinal biopsy is critical, along with a gluten-free
Villous tip intraepithelial lymphocytes as markers of
early-stage coeliac disease.
Scand J Gastroenterol. 2004 May;39(5):428-33.
Jarvinen TT, Collin P, Rasmussen M, Kyronpalo S, Maki M,
Partanen J, Reunala T, Kaukinen K.; Dept. of Internal
Medicine, Tampere University Hospital, Medical School,
University of Tampere, Tampere, Finland.
CONCLUSIONS: Villous tip analysis seems to distinguish
early coeliac from non-specific changes, thus providing
a valuable tool in routine practice, especially when
borderline findings are involved. Its value appears to
be similar to counting of gammadelta+ cells, which,
however, requires frozen biopsy samples.
Range of neurologic disorders in patients with celiac
Pediatrics. 2004 Jun;113(6):1672-6. Zelnik N,
Pacht A, Obeid R, Lerner A.
Department of Pediatrics, Carmel Medical Center,
The Bruce Rappaport
Faculty of Medicine, Technion-Israel Institute of
Technology, Haifa, Israel. email@example.com
OBJECTIVE: During the past 2 decades, celiac disease
(CD) has been recognized as a multisystem autoimmune
disorder. A growing body of distinct neurologic
conditions such as cerebellar ataxia, epilepsy,
myoclonic ataxia, chronic neuropathies, and dementia
have been reported, mainly in middle-aged adults. There
still are insufficient data on the association of CD
with various neurologic disorders in children,
adolescents, and young adults, including more common and
"soft" neurologic conditions, such as headache, learning
disorders, attention-deficit/hyperactivity disorder
(ADHD), and tic disorders. The aim of the present study
is to look for a broader spectrum of neurologic
disorders in CD patients, most of them children or young
CONCLUSION: This study suggests that the variability of
neurologic disorders that occur in CD is broader than
previously reported and includes "softer" and more
common neurologic disorders, such as chronic headache,
developmental delay, hypotonia, and learning disorders
or ADHD. Future longitudinal prospective studies might
better define the full range of these neurologic
disorders and their clinical response to a gluten-free
and Prebiotics in Gastrointestinal Disorders
Curr Opin Gastroenterol 20(2):146-155, 2004. © 2004
Lippincott Williams & Wilkins.
Richard N. Fedorak, Karen L. Madsen. Posted
Recent findings: The demonstration that immune
and epithelial cells can discriminate between different
microbial species has extended the known mechanism(s) of
action of probiotics beyond simple barrier and
antimicrobial effects. It has also confirmed that
probiotic bacteria modulate mucosal and systemic immune
activity and epithelial function. The progressive
unraveling of these mechanisms of action has led to new
credence for the use of probiotics and prebiotics in
clinical medicine. Level I evidence now exists for the
therapeutic use of probiotics in infectious diarrhea in
children, recurrent Clostridium difficile-induced
infections and postoperative pouchitis. Level II
evidence is emerging for the use of probiotics in other
gastrointestinal infections, prevention of postoperative
bacterial translocation, irritable bowel syndrome, and
in both ulcerative colitis and Crohn disease.
Nevertheless, one consistent feature has emerged over
the past year: Not all probiotic bacteria have similar
therapeutic effects. Future clinical trials will need to
incorporate this fact into trial planning and design.
Characteristics and quality of illness behavior in
Psychosomatics. 2004 Jul-Aug;45(4):336-42. de Rosa
A, Troncone A, Vacca M, Ciacci C.
Psychiatry Department, Second University of
Naples, Naples, Italy.
The study evaluated the illness behavior of patients
with celiac disease and the influence of the disease and
its treatment on key personality components and
adherence to dietary recommendations. Twenty-nine adult
patients with celiac disease and 47 matched healthy
comparison subjects participated in the study. More than
70% of the celiac disease group scored in the
pathological range on at least one scale of the Illness
Behavior Questionnaire. Patients who received the
diagnosis in adulthood had a lower score for
nonconformism, a greater tendency to pretend to be
sociable, and higher levels of psychophysiological
reactiveness, relative to the comparison subjects. The
results suggest that celiac disease may be associated
with changes in personality that may interfere with
patients' adaptation to living with a chronic disease.
Screening patients with osteoporosis for celiac disease
(Arch Intern Med. 2005; 165:393-399)
CHICAGO – Results of a new study suggest that the higher
prevalence of celiac disease in individuals with
osteoporosis than in the general population may justify
screening of patients with osteoporosis for celiac
disease, according to an article in the February 28
issue of Archives of Internal Medicine, one of
the JAMA/Archives journals.
Patients with celiac disease have an inappropriate
immune response to gluten, a component of wheat
proteins, which makes it difficult to properly digest
many foods, according to background information in the
article. Although adults diagnosed with celiac disease
commonly have a low bone mineral density (BMD) and
treatment with a gluten-free diet increases their BMD,
there has not been clear evidence of the benefit of
screening everyone with osteoporosis for celiac disease.
William F. Stenson, M.D., of Washington University
School of Medicine, St. Louis, and colleagues evaluated
840 individuals, 266 with and 574 without osteoporosis
from the Washington University Bone Clinic by serologic
screening for celiac disease (blood test for antibodies
associated with celiac disease). The diagnosis of celiac
disease was then confirmed with an intestinal biopsy and
individuals with a confirmed diagnosis were treated with
a gluten-free diet and followed up for improvement in
Twelve of the 266 patients with osteoporosis and six of
those without osteoporosis tested positive by
serological screening for celiac disease, the
researchers found. Nine patients with osteoporosis (3.4
percent) and one of those without osteoporosis (0.2
percent) had biopsy-proven celiac disease. Further, the
authors write, "…the more severe the celiac disease, the
more severe the resulting osteoporosis."
"Treatment with a gluten-free diet for a year resulted
in improved BMD in individuals with celiac disease and
osteoporosis," the authors write. "The improvement in
BMD for celiac disease patients on the gluten-free diet
was greater than that expected for osteoporotic patients
receiving standard therapy."
"In conclusion, we found that the prevalence of celiac
disease among osteoporotic patients was much higher
than among the nonosteoporotic population and high
enough to justify a recommendation that all
individuals with osteoporosis undergo serologic
screening for celiac disease," the researchers state.
"…individuals with positive serological screening
should be evaluated with endoscopy and small-intestine
mucosal biopsy to establish the diagnosis of celiac
disease. Treatment of these individuals with a
gluten-free diet will improve their BMD."
Editorial: Population-Based Screening for Celiac Disease
In an editorial accompanying this study, Alan L. Buchman,
M.D., M.P.H., of the Feinberg School of Medicine at
Northwestern University, Chicago, writes that the
primary reason to diagnose and treat osteoporosis is to
prevent bone fractures. "Low bone mineral density (BMD)
is associated with increased fracture risk, and
increased BMD during therapy is associated with a
corresponding decrease in fracture risk. However, BMD is
only one factor that contributes to bone strength and
fracture risk in spine and hip."
"Given that most bone mass is achieved by age 18 years,
and setting aside cost for the moment, it may be prudent
to screen the entire population of high-risk individuals
(white girls) during childhood or adolescence, prior to
development of osteoporosis or osteopenia," Dr. Buchman
writes. "Even patients diagnosed as having celiac
disease before menopause have more significant
improvements in BMD that those diagnosed after
menopause. However, one must evaluate the cost not just
to identify an asymptomatic individual with celiac
disease, but also to prevent a fracture."
"The cost to prevent a single fracture in a patient with
celiac disease and osteoporosis would be $43,000
(similar to the cost of screening mammography to detect
a breast cancer)," Dr. Buchman states. "This cost would
be far greater for a patient with osteopenia, to say
nothing of a population screen." Dr Buchman also points
out that, "Not all investigations have reported an
increased prevalence of celiac disease in individuals
with osteoporosis or an increased fracture risk in
patients with celiac disease."
"However, the questions remain: Who should be screened
for celiac disease? And at what cost? The data from
Stenson et al raise an important issue, but given the
variations in study findings and cost estimates, it is
impossible to make a clear recommendation for celiac
disease screening in a population even as defined as
those with osteoporosis," Dr. Buchman concludes. "As is
often the case, further study is indicated."
(Arch Intern Med. 2005; 165:370-371. Available
Study Links Osteoporosis, Gluten Intolerance
CHICAGO (Reuters) – 2/28/05
Some people develop osteoporosis, the mineral loss
disease that leads to brittle bones, because their
bodies cannot tolerate wheat flour, a study said on
Gluten intolerance, called celiac disease, can be
treated, so the damage done by osteoporosis can be
reversed in such patients, added the report published in
the current issue of the Archives of Internal Medicine.
"Our results suggest that as many as three to four
percent of patients who have osteoporosis have the bone
disease as a consequence of having celiac disease, which
makes them unable to absorb normal amounts of calcium
and vitamin D," said William Stenson, a Washington
University physician at Barnes-Jewish Hospital in St.
Louis. He and colleagues recommended blood tests be used
to screen osteoporosis patients for celiac disease. The
report was based on a look at 840 patients, some of whom
had osteoporosis. It found a much higher prevalence of
celiac disease among those with osteoporosis than in
those without it.
Celiac disease triggers an immune reaction to the gluten
portion of wheat, interfering with the intestine's
absorption of various foods. Some patients do not know
they have the disease because their symptoms are minor.
In the study, patients with celiac disease and
osteoporosis who went on a gluten-free diet for one year
were able to improve both gastrointestinal symptoms and
bone density, the report said. "Bone density ...
improved dramatically on a gluten-free diet," Stenson
said. "We believe the diet allowed their intestines to
heal, and that allowed them to absorb normal amounts of
calcium and vitamin D to reverse bone loss."
While there is a genetic predisposition for celiac
disease, many people don't develop symptoms until later
in life, Stenson said.