• Join our community!

    Do you have questions about celiac disease or the gluten-free diet?

  • Ads by Google:

    Get email alertsSubscribe to Celiac.com's FREE weekly eNewsletter
    Ads by Google:


       Get email alertsSubscribe to Celiac.com's FREE weekly eNewsletter

  • Member Statistics

    83,191
    Total Members
    4,125
    Most Online
    tariann918
    Newest Member
    tariann918
    Joined
  • 0

    Interpretation of Celiac Disease Blood Test Results


    Scott Adams
    Interpretation of Celiac Disease Blood Test Results
    Image Caption: Images: CC--Scott Robinson

    The following detailed explanation of serological tests for celiac disease was written by Tom Ryan, Technical Service Specialist, INOVA Diagnostics, Inc.


    Ads by Google:




    ARTICLE CONTINUES BELOW ADS
    Ads by Google:



    There has been a lot of discussion about serological testing for celiac disease recently, specifically regarding tTG (tissue Transglutaminase) testing. I will try to answer some of the many questions that have appeared on this list about all of the tests. First, and this applies to any of the blood tests, you must currently be on a gluten containing diet for the tests to be accurate. Antibodies are produced by the immune system in response to substances that the body perceives as threatening. The immune response that your body produces is its response to being exposed to gluten in the diet and its subsequent effect on the intestinal mucosa. If there is no gluten in the diet, then there is no response that we can measure. A brief change in diet will not have a noticeable effect. If you have been gluten free for a week or so, it will not make any great difference. The response might be marginally less but the difference is insignificant because the body has not had time to respond to the change. Conversely, if you have been gluten free for a protracted period of time and decide to be tested, a brief challenge of a couple of weeks is not enough to elicit a response and get an accurate test.

    There are several steps that take place to generate an immune response and it takes time both for the positive reaction when gluten is present and to clear the antibodies when gluten is eliminated. There has been a great deal of discussion about how much and how long a challenge should be and there is no consensus. Talk with your Doctor. My personal feeling is that the minimum is 2 slices of bread per day for 6 weeks to get an accurate test but I would not try to second-guess the Doctor. There are basically four tests that can be performed to aid in diagnosing celiac disease. Notice that I say they will aid in diagnosing celiac disease. Immunology is fairly accurate but it is far from being an exact science. All of the lab tests, regardless of the type or source, are presented as aids to diagnosis. They should not be used alone as a basis for diagnosis but rather are intended to be considered in conjunction with the physical examination of the patient as well as the reported symptoms, etc. by a trained physician. There has been a great deal of confusion about what the tests are and I hope to alleviate some of the misunderstandings. There are many terms that we hear. tTG, IgA, IgG, ELISA, etc. What are all of these? Some contributors to the list make reference to the IgA or IgG test or to the ELISA test. These labels are incomplete for our purposes and could be referring to any number of different tests.

    We all have, within our bodies, a family of closely related although not identical proteins which are capable of acting as antibodies. These are collectively referred to as immunoglobulins. Five major types of immunoglobulins are normally present in the human adult. They are IgG, IgA, IgM, IgE and IgD. Each of these is a shorthand way of writing immunoglobulin gamma G (or A or M, etc.) and they each perform a different function in our systems. IgG is the principal immunoglobulin in human serum. It is important in providing immunity in a developing fetus because it will pass across the placental barrier. IgA is the principal immunoglobulin in secretions from respiratory and intestinal mucosa. IgE is a gamma globulin produced by cells lining the intestinal and respiratory tracts. It produces the antibodies associated with most hypersensitivity (allergic) responses. It is associated with asthma, hay fever, etc. IgM is a globulin formed in almost every immune response in the early part of the reaction. IgD is a rare protein present in normal sera in a tiny amount. These designations refer to the type of protein that is carrying the antibody in question. Both IgG and IgA subtypes of anti-gliadin antibody are produced, hence we refer to them as IgG gliadin or IgA gliadin. Collectively they are anti-gliadin antibodies.

    Anti-Gliadin Antibodies:

    Both IgA and IgG anti-gliadin antibodies (AGA) are detected in sera of patients with gluten sensitive enteropathy (celiac disease). IgG anti-gliadin antibodies are more sensitive but are less specific markers for disease compared with IgA class antibodies. IgA anti-gliadin antibodies are less sensitive but are more specific. In clinical trials, the IgA antibodies have a specificity of 97% but the sensitivity is only 71%. That means that, if a patient is IgA positive, there is a 97% probability that they have celiac disease. Conversely, if the patient is IgA negative, there is only a 71% probability that the patient is truly negative for celiac disease. Therefore, a positive result is a strong indication that the patient has the disease but a negative result does not necessarily mean that they don not have it. False positive results are rather uncommon but false negative results can occur. On the other hand, the IgG anti-gliadin antibodies are 91% specific and have an 87% sensitivity. This means that they will show positive results more readily but there is not as strong a correlation with celiac disease. It is less specific. Patients with other conditions but not afflicted with celiac disease will occasionally show positive results. IgG anti-gliadin antibodies are detectable in approximately 21% of patients with other gastrointestinal disorders. This test might yield false positive results but is less likely to yield false negative results.

    A sensitive testing protocol includes testing for both IgA and IgG anti-gliadin antibodies since a significant portion of celiac patients (approx. 2-5%) are IgA deficient. This combined IgA and IgG anti-gliadin antibody assay has an overall sensitivity of 95% with a specificity of 90%. The type of test used to detect the anti-gliadin antibodies is called an ELISA. This is an acronym and it stands for Enzyme Linked Immuno-Sorbent Assay. ELISA is not a test in itself. It is a method of testing and it is a relatively simple test to perform. It involves putting a measured amount of diluted patient serum into the wells of a specially constructed and prepared plate and incubating it for a period of time with various chemicals. The end result is a color change, the intensity of which is dependent upon the concentration of anti-gliadin antibody (or other protein being measured) in the patient serum. The ability of this colored solution to absorb light at a particular wavelength can be measured on a laboratory instrument and mathematically compared with solutions that contain a known amount of anti-gliadin antibody to arrive at a number for the amount of antibody present. The sample can then be classified as negative, (0-20 units); weak positive, (21-30 units); or moderate to strong positive if greater than 30 units. The purpose of testing for anti-gliadin antibodies includes, in addition to diagnosis of gluten sensitive enteropathy, monitoring for compliance to a gluten free diet. IgA gliadin antibodies increase rapidly in response to gluten in the diet and decrease rapidly when gluten is absent from the diet. The IgA anti-gliadin antibodies can totally disappear in 2-6 months on a gluten free diet, so they are useful as a diet control. By contrast, IgG anti-gliadin antibodies need a long time, sometimes more than a year, to become negative. The reverse is also true. That is, a patient with celiac disease who has been on a gluten free diet and tests negative for IgA anti-gliadin antibodies, will show a rapid increase in antibody production when challenged by gluten in the diet. Approximately 90% of challenged patients will yield a positive IgA anti-gliadin result within 14-35 days after being challenged. The IgG antibodies are somewhat slower.

    Endomysial Antibodies:

    IgA class anti-endomysial antibodies (AEA) are very specific, occurring only in celiac disease and DH. These antibodies are found in approximately 80% of patients with DH and in essentially 100% of patients with active celiac disease. IgA endomysial antibodies are more sensitive and specific than gliadin antibodies for diagnosis of celiac disease. Antibody titers (dilutions) are found to parallel morphological changes in the jejunum and can also be used to reflect compliance with gluten-free diets. Titers decrease or become negative in patients on gluten free diets and reappear upon gluten challenge.

    The test for anti-endomysial antibodies is more subjective and more complicated for the lab to perform than the anti-gliadin assays. It involves serially diluting some of the patients serum, that is, diluting it by ½ then ¼, 1/8, 1/16, etc. and putting these dilutions on a glass slide that has some sort of tissue affixed to it. The slide is then processed with various solutions and examined under a fluorescent microscope to determine if any of that serum binds to any of the proteins in the tissue. If so, then that patient is confirmed as having antibodies to that particular protein. This method of testing is called an IFA or sometimes IIFA. It stands for Indirect Immuno-Fluorescent Assay. The selection of which tissue slide to use is determined by what specific protein, hence which antibody, you are specifically looking for. Endomysial antibodies react with the endomysium, which is a sheath of reticular fibrils that surround each muscle fiber. Therefore, to detect endomysial antibodies, you would want to use a tissue substrate that contains a lot of muscle tissue. The substrate used most often for this assay is distal sections of the esophagus. These are very thinly sliced and fixed to the slide. They contain muscle fibers and not much else so there is a lot of endomysium available to react with the anti-endomysial antibodies.

    Reading this test involves viewing the reacted slides with a fluorescent microscope to make the determination. This requires a highly skilled and trained eye and, of necessity, is somewhat subjective. You are looking for a green fluorescence in the endomysium covering the muscle fibers. The test is reported as the titer or final dilution in which the fluorescence can still clearly be seen. As you can imagine, this is very subjective. There are no standardized values and it is up to the judgment of the particular technician what the endpoint titer is. Recently, (1998) the endomysial antigen targeted by the anti-endomysial antibodies was identified as the protein cross-linking enzyme known as tissue transglutaminase (tTG). This has enabled the production of an antigen specific ELISA assay incorporating tTG as a reliable and objective alternative to the traditional and subjective Immunofluorescence based assays. In clinical trials, the correlation with the endomysial IFA assay has been shown to be close to 100%. This is a test that has been very well received in the professional community. It is an ELISA, like the anti-gliadin antibody test and, as such, is not subject to interpretation like the IFA. That is the greatest advantage to this new test! With this or any ELISA, the response is measured on an instrument that calculates the amount of light of a particular wavelength that is absorbed by the solution and prints out a numerical result. There is no chance of human error skewing the results because there is no judgment call involved. The ELISA plate, regardless of what you are testing for, is processed with at least three control sera (sometimes as many as eight) in addition to the unknown sample being tested. There is a negative serum and at least two positive sera containing different levels of the antibody being tested. There are specific requirements for the absorption levels of these three controls. That is, each of them has a minimum or maximum (or both) number that must be seen by the instrument in order for it to be a valid test. If there is any variance from these expected numbers, it is an indication that something went wrong and the test results are discarded and the test repeated. There is therefore no way the technician could report inaccurate results, (assuming they diluted the sample correctly). Either the test was valid, and you can rely upon the accuracy of the result, or the test is invalid, and the entire result discarded. If any error was made during the processing of the ELISA plate, it would result in the control sera numbers being out of range and the entire test result would be thrown out.

    In summary, the tTG ELISA is measuring the same thing that the endomysial IFA is measuring but with a method that is more sensitive and specific and not subject to interpretation. IgA class Reticulin antibodies are found only in Celiac disease and dermatitis herpetiformis. These antibodies are found in approximately 60% of celiac disease patients and 25% of DH patients. This test is falling into disuse because of the limited utility and the availability of better tests. It is an IFA performed on a tissue substrate with all the attendant problems that go along with it. The development of all of these serum assays has tremendously simplified the diagnosis of celiac disease and improved the accuracy as well. The original criteria for diagnosis according to the European Society for Pediatric Gastroenterology and Nutrition, (ESPGAN), involved a year of arduous studies with:

    • An initial positive gut biopsy;
    • 6 months on a gluten free diet;
    • A second, negative gut biopsy;
    • A gluten challenge for 6 months and;
    • A third, positive gut biopsy. The revised ESPGAN criteria call for positive results in two of the serological tests confirmed by a single positive biopsy. In practice, many gastroenterologists are utilizing the serologies in conjunction with a controlled diet and the clinical presentation to form a basis for diagnosis without the need for the invasive procedure.

    Through the auspices of the Celiac Disease Foundation and others, a professional symposium and workshop was organized earlier this year in Marina Del Rey, California with participants from Europe as well as the U.S. to establish standards for reporting test results. This should improve testing and diagnosis even more. At the conclusion of this conference a Celiac Disease Standardization Committee was formed to investigate and make recommendations on a standardized method of reporting results.

    Edited by admin

    0


    User Feedback

    Recommended Comments



    Guest michelle

    Posted

    very well written - I could understand it.

    Share this comment


    Link to comment
    Share on other sites

    Very well presented. Those of us who are not medically trained can understand it.

    Share this comment


    Link to comment
    Share on other sites

    This is definately one of the best article I have read on celiac blood tests. Thank you!

    Share this comment


    Link to comment
    Share on other sites
    Guest Nancy

    Posted

    Great explanation of the tests, now I know what to ask the doctor for to make sure they run all the necessary tests.

    Share this comment


    Link to comment
    Share on other sites
    Guest Michelle

    Posted

    Finally an explanation I can understand.Thank you.

    Share this comment


    Link to comment
    Share on other sites
    Guest Rachel

    Posted

    Great article - the only one I found online that came close to explaining the IgA and IgG ELISA in terms I could understand (my doctor is a bit ADD.) But now I have more questions. On my IgA and IgG ELISA test results for food sensitivity, my 'big ones' were yeasts, milk products, and nuts. On both the IgA and IgG tests I had much lower reactions to gluten / grainy products in general. I wasn't on a gluten free diet when I tested, but still had not been a big bread or grain eater in general. But now I'm wondering if registering a positive on both tests is something to think further about. I did read somewhere that sensitivity to milk products can produce results similar to gluten sensitivity? Any thoughts on that?

    Share this comment


    Link to comment
    Share on other sites
    Guest Susan

    Posted

    Thank you this was very clear and helpful.

    Share this comment


    Link to comment
    Share on other sites
    Guest Lenore

    Posted

    Now I have a better concept of what was tested, why, the validity and how I can better understand my own test results.

    Share this comment


    Link to comment
    Share on other sites
    Guest Kathleen Taylor

    Posted

    Now I understand! I think the dermatologist and gastroenterologist thought it was too complicated to explain - and thus I did not take them seriously!

    Share this comment


    Link to comment
    Share on other sites
    Guest Deborah

    Posted

    I wish I had read this before testing. I have been on a gluten free diet almost all the time for 10 months, and thought that the antibodies would show up on the test if I ate wheat the day before testing. I think my tests are false negative, but definitely don't want to undergo biopsy to prove it.

    Share this comment


    Link to comment
    Share on other sites

    It seems cruel and unnecessary to put someone back on a diet containing gluten after 6 months of being gluten free. I quit eating gluten after my mother and sister were diagnosed with celiac . I feel so much better that I don't need a 'confirmation ' by a doctor or invasive procedure.

    Share this comment


    Link to comment
    Share on other sites
    Guest Heather kerekffy

    Posted

    Finally an explanation! I was low on my IgA but high positive on IgG and so sick and my doc said, 'at some point in the past, gluten made you very sick, but you're fine now.'.. He was totally ignoring my symptoms! That was two years ago and he still doesn't believe I have it, even though since then he diagnosed me with osteopenia.. I've been off gluten for about 3 months now, and my chronic migraines and stomach problems are gone! my doc still doesn't believe I have it, but IBS instead! give me a break! And these are Seattle gastroenterologists!

    Share this comment


    Link to comment
    Share on other sites

    Great article. I finally understood better the interpretation of the test results. I would like to see a table of the combination of tests usually done, the results (negative, positive) and possible interpretation of whether or not the disease can be presumed. I tested positive for anti gliadin IgA and negative for anti endomysium Iga and the doctor really does not know the meaning. My sister is confirmed celiac and I have IBS symptoms.

    Share this comment


    Link to comment
    Share on other sites

    My doctor ordered the IGA test knowing that I've been on a gluten free diet for 4 months. It came out negative & took me out of the diet. Now I'm back to my old diarrhea nightmare. Now I know why. I'll definitely go back to my gluten free diet! Thanks!

    Share this comment


    Link to comment
    Share on other sites
    Guest Jill from UK

    Posted

    Thank you for explaining the whole testing sequence in simple terms so that I can understand them.

    Share this comment


    Link to comment
    Share on other sites
    Guest Shelia  Ryan

    Posted

    Very interesting. I am having more testing and hopefully people will realize I was not a fussy eater. The food did not agree with me.

    Share this comment


    Link to comment
    Share on other sites
    Guest Sharese

    Posted

    This article is the best. It really explained my sons results and I fully understand that he definitely has a gluten sensitivity. I printed it to share with other moms at my sons school. Even my PCP didn't know how to interpret it..I'm a RN and I found this to be very simple and informative.

    Share this comment


    Link to comment
    Share on other sites

    In the hopes this will help someone, I'm posting my before and after Celiac panel test results.

     

    On 4/10/09 (diagnosed)

    Deamidated Gliad IgAH 127

    Deaminated Gliad IgGH 104

    Tranglut IgA 43

     

    On 6/12/09 (gluten free diet)

    127 -> 58 (goal under 10)

    104-> 48 (goal under 10)

    43 -> 10 (goal under 3)

     

    So after being on gluten free diet from 4/10/09-6/12/09, 8 weeks, already seeing dramatic reductions in antibody levels. Not done yet, but are headed in the right direction. I didn't see this kind of information posted anywhere, so hoping this information is helpful.

    Share this comment


    Link to comment
    Share on other sites
    Guest Lisa Shroyer

    Posted

    Thank you for putting a complicated process into words that the patient can understand. I have spent hours poring over material and couldn't understand it or it was simply to vague. I finally understand what my doctor is saying to me.

    Share this comment


    Link to comment
    Share on other sites

    Thanks for this. You mentioned that "IgG anti-gliadin antibodies are detectable in approximately 21% of patients with other gastrointestinal disorders."

     

    What other gastrointestinal disorders could also come back positive with IgG? Is it possible to have a positive IgG but be disease-free?

    Share this comment


    Link to comment
    Share on other sites
    Guest Susan Tees

    Posted

    I keep coming back to this wonderful article for reference. Wonderfully thorough and scientific.

    Share this comment


    Link to comment
    Share on other sites
    Guest Maggie L.

    Posted

    I'm getting the blood panel tomorrow. In the past 10 years, I have avoided gluten since it made me bloated. I've also had fertility issues, osteopenia, floating stools, and signs of vitamin deficiency. Recently, I've been unknowingly eating gluten in the form of oats for about 6 weeks. After researching celiac online, I've decided to get tested. But now I realize that I might get a false negative. We'll see... I'll bet there are others out there in my same situation, so I'll let you know my test results and what I plan to do. The thought of pasta, pastries and sandwiches makes my head happy, (Happy Holidays!), but I know my gut will be miserable, just to prove a diagnosis.

    Share this comment


    Link to comment
    Share on other sites
    Guest Adolph Schaber

    Posted

    I am still a bit confused. I have a high gliadin IgA Ab at 75 High, and a negative Gliadin IGG ab at 27.0. My Transglutaminiase IGA autoab was 4.0 and my Endomysial IgA was negative and my Immunoglobulin A was 332.0 Does this mean that because only my Gliadin IgA ab was abnormally high that I don't have celiac disease being that the other antibodies were within normal limits. What does a high Gliadin IGA AB represent.

    Share this comment


    Link to comment
    Share on other sites
    Guest Phillipa Sheard

    Posted

    In order for you to get a true test result you can not eat out. Gluten is in everything. Dry beans are persevered with Wheat, as Scott Adams said to me a couple of days " The Food May Be Cross Contaminated" Try to eat veggies,or anything you feel in manufactures can be cross contaminated with Gluten and then go take another Panel.

    Share this comment


    Link to comment
    Share on other sites



    Your content will need to be approved by a moderator

    Guest
    You are commenting as a guest. If you have an account, please sign in.
    Add a comment...

    ×   Pasted as rich text.   Paste as plain text instead

      Only 75 emoji are allowed.

    ×   Your link has been automatically embedded.   Display as a link instead

    ×   Your previous content has been restored.   Clear editor

    ×   You cannot paste images directly. Upload or insert images from URL.


  • Popular Contributors

  • Who's Online   15 Members, 1 Anonymous, 218 Guests (See full list)

  • Related Articles

    Scott Adams
    Great Smokies Diagnostic Laboratory (GSDL), a private, rapid-growth Functional Medicine Clinical laboratory, announced today receipt of 510(K) market clearance from the Food and Drug Administration (FDA) for its Intestinal Permeability test kit, utilizing the lactulose-mannitol challenge drink. Used in the non-invasive assessment of intestinal permeability, the test demonstrated its superior sensitivity as compared to the existing d-xylose test in measuring intestinal permeability, a measurement used in the diagnosis of gastrointestinal malabsorption syndromes, such as celiac disease, colitis, Crohns disease, and Irritable Bowel Syndrome.
    What is intestinal permeability?
    Intestinal permeability refers to impairment of the intestinal mucosal barrier, which is central to healthy absorption of nutrients and protection against bacterial and toxin translocation from the gastrointestinal (GI) tract to the blood stream. Disturbances in mucosal barrier function can lead to malnourishment and increased permeability (leaky gut) which can cause or contribute to disease conditions throughout the body as diverse as asthma, arthritis, and food allergies.
    What are gastrointestinal malabsorption syndromes?
    Although the Centers for Disease Control (celiac disease) has not gathered statistics specifically for malabsorption itself, tens of millions of Americans suffer from related gut mucosal integrity conditions responsible for enormous healthcare expense. Arthritis, for example, strikes over 43 million annually at a cost of more than $65 million (celiac disease), while functional gastrointestinal disorders are responsible for an estimated 2.5 to 3.5 million visits to doctors every year and some $40 million in medication expenditures (University of North Carolina Functional Gastrointestinal Disorders Center). The incidence of these health disorders and other intestinal permeability related- conditions continues to grow at an alarming rate.
    The growing use of non-steroidal anti-inflammatory drugs (NSAIDS), which can irritate the mucosal lining, has contributed significantly to an increase intestinal permeability worldwide. Intestinal Permeability Assessment can be used to monitor treatment of NSAID-related damage to the mucosal barrier and intestinal permeability-related to other irritants in the GI tract. An estimated 20% or more of patients taking NSAIDS develop systematic or endoscopic gastrointestinal toxicity with incidence increasing among the elderly, who account for 40-60% of NSAID users (Canadian Medical Association Journal 1996; 155: 77-88).
    Inflammatory and detoxification disorders, impaired healing following surgery, failure to thrive, and complications from radiation and chemotherapy for cancer have all been linked to intestinal permeability. Recent research has consistently underscored the value of Intestinal Permeability Assessment in GI disorders such as Crohns and Irritable Bowel Syndrome, as well as traumatic care, geriatric interventions, adjunctive AIDS therapy, and pediatric care, especially in the treatment of allergies and immune disorders.
    GSDL is the first commercial laboratory to offer Intestinal permeability testing. Utilizing state-of-the art technology, GSDL has developed a comprehensive range of functional assessments in the areas of gastroenterology, endocrinology, cardiology, nutrition/metabolism, and immunology. The laboratory conducts aggressive, ongoing research and development for innovative functional assessments.

    Dr. Rodney Ford M.D.
    This article appeared in the Summer 2007 edition of Celiac.com's Scott-Free Newsletter.
    This question, “how early can you diagnose celiac disease?” is a major concern for both parents and paediatricians.  This is because, like many diseases, celiac disease comes on slowly.  This means that it can take a long time to make the diagnosis.
    Celiac disease can develop slowly?
    Yes, celiac disease can develop very slowly.  The symptoms can be subtle.  It is a progressive disease.  When you are first born, you cannot have celiac disease as you have never been exposed to gluten.  However, if you have the right genetic make up (that is you have the celiac gene) and the right environmental circumstances (eating gluten and getting gut inflammation), then celiac disease can develop.
    Finding tissue damage
    Celiac disease is a condition that is recognised when you get damage to your small bowel tissue.  This damage is triggered by gluten.
    The standard way to detect this tissue damage is by taking a gut biopsy of the small bowel skin (also called the mucosa).  This is done by the technique of upper endoscopy whilst under an anaesthetic.  Tiny fragments of gut tissue are snipped off with a pair of forceps.   This tissue is then sent to a pathology lab.  The lab people (histologists) look down their microscopes at this tissue sample.  They are looking for the gut damage called villous atrophy which is characteristic of disease.
    Early antibody changes – IgG-gliadin
    Importantly, long before the tissue becomes obviously damaged by gluten, your body can begin to react to the gluten in your diet.
    An early sign of a gluten immune reaction is that your body produces antibodies to the gluten in your diet.  This can be seen in a blood test that looks for an antibody called the IgG-gliadin antibody (also known as anti-gliadin-antibody).  Also the IgA-gliadin antibody can develop at this time.
    Even in these early stages of gluten reactions (before the development of any gut damage of celiac disease), you or your child can be feeling unwell.  Many of the symptoms of celiac disease can be recognized in these early stages.  This is before the tissue damage can be seen by the histologist.
    The blood test to look for tissue damage is called the tissue transglutaminase antibody (abbreviated as tTG).
    Early bowel damage cannot be seen
    The next thing to happen is that the tissue in the small bowel gets slightly injured but not enough to be identified by the histologist.  However, such damage can be shown by an electron microscope.  This early damage can also be detected by the presence of the tTG antibody.
    Usually, when the tTG blood test goes up, then this is an indication to do the endoscopy and look for any tissue damage.  However, early in the progression of celiac disease, this damage may not show up by conventional methods.  This means that the small bowel biopsy and the histology results are good for confirming celiac disease, but they cannot rule it out.
    To act or to wait?
    In my experience, I have seen a number of children develop celiac disease whilst I have watched and waited.  While we doctors wait and see if the gut will become progressively damaged, these children will continue to experience their gut symptoms and they may not be growing so well. We doctors are waiting to make a certain diagnosis of celiac disease.  We want to repeat their blood tests and do another endoscopy.
    Is this reasonable?  Experience has changed my mind.  I have come to the conclusion that this is not an appropriate way to deal with these children.  Currently, most medical specialists are adamant. They will not make a diagnosis of celiac disease until the histologist can confirm the typical tissue damage.
    How long can you wait?
    I have given up the “wait and see” approach.  I act.  I carefully scrutinize the symptoms and the blood test results - the gluten antibodies (IgG-gliadin) and tissue damage antibody (tTG) levels.  I may organise an endoscopy test.  If these findings suggest the development of celiac disease, then I make a pre-emptive diagnosis of “early celiac disease”, often before the gut gets badly damaged.  I give these children a trial of a gluten-free diet – I see what their clinical response is.  Pleasingly, most get completely better!  If they get better, then they want to stay gluten-free.
    The problem is that the diagnosis of celiac disease currently hinges on the abnormal appearance of the small bowel.  This damage can take years to develop.  
    The main argument against my approach is that if you do not have a “definite” diagnosis of celiac disease, then you cannot advise a gluten-free diet for life.  In my opinion, the decision to go on a gluten-free diet is not a black and white choice.  For children, I give them the option of a gluten-free diet early in their disease.  Let them feel well.  Let them grow properly.  Later, as an adult, they can challenge their diagnosis and have a formal gluten challenge when they understand the issues.       
    Conclusion – my approach
    As you can see, it is difficult to say how early you can diagnose celiac disease.  It is my practice to carefully assess children regarding their symptoms, their antibody levels, their genetic status and their endoscopy results (if appropriate).
    I do not think it is logical to leave children with significant symptoms waiting for the small bowel damage to eventually occur.  Indeed, I think that these long delays in treatment are inhumane.  Postponement of a gluten-free diet will cause these children to suffer ongoing symptoms.  Worse, they can have growth failure, from which they may not recover.
    My approach is to put these children on a gluten-free diet early.  I watch and see if thy have a clinical response: if they get better.   The evidence shows that you cannot rely entirely on the small bowel biopsy for your diagnosis of celiac disease.  These children can have a gluten challenge later in their lives.
    The onset of celiac disease is progressive.  Why wait until the bitter end before going gluten-free? The onset of celiac disease is progressive.  Why wait until the bitter end before going gluten-free?  You can find out a lot more from my webpage: www.doctorgluten.com


    Jefferson Adams
    Celiac.com 08/11/2009 - While the use of anti-tTG antibodies is common practice in the diagnosis of celiac disease, their value in long-term follow-up remains controversial. A team of researchers recently set out to assess the value of anti-tTG antibodies in long-term follow-up.
    The research team was made up of C.R. Dipper, S. Maitra, R. Thomas, C.A. Lamb, A.P.C. McLean-Tooke, R. Ward, D. Smith, G. Spickett, and J.C. Mansfield. Their goal was to see if they could use serial anti-tTG antibody levels to gauge adherence to a gluten-free diet (GFD) and to spot patients facing complications from celiac disease.
    Researchers conducted a cohort follow-up study of 182 adult subjects over 54-months. The team charted patient self-assessment of gluten-free diet adherence; anti-tTG antibody concentration and serum ferritin, vitamin B12 and folate. When possible, they measured bone mineral density (BMD) and duodenal histology.
    The team found that patients with persistently high anti-tTG antibody levels commonly showed abnormal duodenal histology (P < 0.001), low ferritin (P < 0.01) and poor adherence to the GFD (P < 0.001).
    Anti-tTG antibody specificity was > 85% while the sensitivity was 39–60%. Anti-tTG antibody concentrations fell rapidly following successful implementation of a gluten-free diet, and remained normal in those who faithfully followed the gluten-free diet.
    From these results, the team advocates the use of anti-tTG antibody concentrations to monitor newly diagnosed and established patients with celiac disease, and to target dietary intervention accordingly to reduce the risk of long-term problems.

    Alimentary Pharmacology & Therapeutics. 2009;30(3):236-244.


  • Recent Articles

    Jefferson Adams
    Did You Miss the Gluten-Free Fireworks This Past Fourth of July?
    Celiac.com 08/14/2018 - Occasionally, Celiac.com learns of an amusing gluten-free story after the fact. Such is the case of the “Gluten-Free Fireworks.” 
    We recently learned about a funny little event that happened leading up to Fourth of July celebrations in the town of Springdale in Northwest Arkansas. It seems that a sign advertising "Gluten Free Fireworks" popped up near a fireworks stand on interstate 49 in Springdale. 
    In case you missed the recent dose of Fourth of July humor, in an effort to attract customers and provide a bit of holiday levity, Pinnacle Fireworks put up a sign advertising "gluten-free fireworks.” 
    The small company is owned by Adam Keeley and his father. "A lot of the people that come in want to crack a joke right along with you," Keeley said. "Every now and then, you will get someone that comes in and says so fireworks are supposed to be gluten-free right? Have I been buying fireworks that have gluten? So then I say no, no they are gluten-free. It's just a little fun."
    Keeley said that their stand saw a steady flow of customers in the week leading up to the Fourth. In addition to selling “gluten-free” fireworks, each fireworks package sold by Pinnacle features a QR code. The code can be scanned with a smartphone. The link leads to a video showing what the fireworks look like.
    We at Celiac.com hope you and your family had a safe, enjoyable, and, yes, gluten-free Fourth of July. Stay tuned for more on gluten-free fireworks and other zany, tongue-in-cheek stories.
    Read more at kark.com
     

    Jefferson Adams
    Stress-Related Disorders Associated with Higher Risk for Autoimmune Disease
    Celiac.com 08/13/2018 - It’s not uncommon for people to have psychiatric reactions to stressful life events, and these reactions may trigger some immune dysfunction. Researchers don’t yet know whether such reactions increase overall risk of autoimmune disease.
    Are psychiatric reactions induced by trauma or other life stressors associated with subsequent risk of autoimmune disease? Are stress-related disorders significantly associated with risk of subsequent autoimmune disease?
    A team of researchers recently set out to determine whether there is an association between stress-related disorders and subsequent autoimmune disease. The research team included Huan Song, MD, PhD; Fang Fang, MD, PhD; Gunnar Tomasson, MD, PhD; Filip K. Arnberg, PhD; David Mataix-Cols, PhD; Lorena Fernández de la Cruz, PhD; Catarina Almqvist, MD, PhD; Katja Fall, MD, PhD; Unnur A. Valdimarsdóttir, PhD.
    They are variously affiliated with the Center of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland; the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; the Department of Epidemiology and Biostatistics, Faculty of Medicine, University of Iceland, Reykjavík, Iceland; the Department of Rheumatology, University Hospital, Reykjavík, Iceland; the Centre for Rheumatology Research, University Hospital, Reykjavík, Iceland; the National Centre for Disaster Psychiatry, Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden; the Stress Research Institute, Stockholm University, Stockholm, Sweden; the Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; the Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden; the Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden; the Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden; the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; and the Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
    The team conducted a Swedish register-based retrospective cohort study that included 106, 464 patients with stress-related disorders, 1,064 ,640 matched unexposed individuals, and 126 ,652 full siblings to determine whether a clinical diagnosis of stress-related disorders was significantly associated with an increased risk of autoimmune disease.
    The team identified stress-related disorder and autoimmune diseases using the National Patient Register. They used Cox model to estimate hazard ratios (HRs) with 95% CIs of 41 autoimmune diseases beyond 1 year after the diagnosis of stress-related disorders, controlling for multiple risk factors.
    The data showed that being diagnosed with a stress-related disorder, such as post-traumatic stress disorder, acute stress reaction, adjustment disorder, and other stress reactions, was significantly associated with an increased risk of autoimmune disease, compared with matched unexposed individuals. The team is calling for further studies to better understand the associations and the underlying factors.
    Source:
    JAMA. 2018;319(23):2388-2400. doi:10.1001/jama.2018.7028  

    Jefferson Adams
    Gluten-Free Bacon-Wrapped Chicken Breasts
    Celiac.com 08/11/2018 - Need a quick, easy, reliable gluten-free dish that will satisfy everyone and leave the cook with plenty of time to relax? This recipe is sure to do the trick. Best of all, it's super easy. Just grab some chicken breasts, season them, hit them with a sprig of rosemary, wrap some bacon around them, and chuck them on the grill and call it dinner. Okay, you can add some rice and veggies.
    Ingredients:
    4 skinless, boneless chicken breast halves 4 thick slices bacon 4 teaspoons garlic powder 4 small sprigs fresh rosemary salt and pepper to taste Directions:
    Heat an outdoor grill to medium-high heat, and lightly oil the grate.
    Sprinkle 1 teaspoon garlic powder on a chicken breast and season with salt and pepper. 
    Place a rosemary sprig on each chicken breast. 
    Wrap the bacon around the chicken and the rosemary. 
    Hold bacon in place with a toothpick or extra rosemary stem.
    Cook the chicken breasts until no longer pink in the center and the juices run clear, about 8 minutes per side. 
    Keep an eye out for any grill flare ups from the bacon grease. 
    Remove the toothpicks and serve with steamed rice and your favorite vegetables for a winning meal.

    Connie Sarros
    Five-Minute Healthy Breakfasts
    Celiac.com 08/10/2018 - You’ve heard for years that it’s wise to start your day with a healthy breakfast.  Eating food first thing in the morning gets your metabolism revved so you have energy throughout the day.  There’s also the issue of incorporating healthy foods into your first meal of the day.  Ideally, every meal should include fiber and foods from a variety of food groups.  But the reality is that most people don’t have time in the morning to create an involved meal.  You’re busy getting ready for work, packing the kids’ lunches and trying to get everyone out of the door on time.  
    Don’t fret.  The task of preparing a healthy breakfast just got easier.  You can make 5-minute breakfasts and, with a little bit of planning, you can sneak fiber into those meals without spending a lot of extra time with preparation.  An ideal breakfast will include whole grains (from gluten-free cereals, breads, muffins, or uncontaminated oats), a low-fat dairy item (1% milk, low-fat yogurt, or low-fat cheese), and a source of protein (such as peanut butter or eggs).  Adding fruit is a plus.  
    If you can tolerate uncontaminated oats, make a bowl of oatmeal and add a little extra fiber by stirring in chopped walnuts and dried cranberries.  If you like scrambled eggs, toss some fresh spinach (sliced into thin strips), 1 chopped canned artichoke heart, two tablespoons crumbled feta cheese, and a dash of Italian seasoning to the egg as it cooks.  
    If you have time on weekends to make healthy gluten-free pancakes (which  means that you added perhaps flax seed meal or shredded apples or something that qualifies as fiber to the batter), then freeze the pancakes between sheets of wax paper, place them in a freezer bag, and freeze so they’ll be handy on busy weekday mornings.  If you don’t have time to make them prior to need, you can always use commercial frozen gluten-free pancakes.  In a bowl, mix together a few raisins, half of a chopped pear or apple, a few dashes of cinnamon and a couple of tablespoons of chopped walnuts.  Spoon this mixture down the centers of two toasted (or microwaved) pancakes, drizzle each with 1 teaspoon of pancake or maple syrup, then fold in the sides of the pancakes to make two breakfast sandwiches.
    Brown rice is brown because the bran layer is still on the rice, and the bran layer is the part that’s so high in fiber.  White rice is much lower in fiber and has less nutritional value.  Brown rice isn’t just for dinner anymore.  It offers a nice breakfast alternative from traditional hot cereals.  The next time you make brown rice for dinner, make a little extra and save some for breakfast the next morning.  In the A.M., mix the rice (about 1 cup) with a few chopped pecans, a few raisins, 1/2 cup milk, 3 tablespoons pancake syrup, a dash each of vanilla and cinnamon, then microwave the mixture for 1 minute, stirring once after 30 seconds.  Let it sit for 30 seconds to thicken before eating.  Or stir together 1 cup cooked brown rice, 1/4 teaspoon cinnamon, 1/2 navel orange diced, some chopped dates, dried cranberries, and shredded coconut; heat this in the microwave and then top it off with 1/2 cup low-fat vanilla yogurt.
    Just a note about using the microwave—it’s not an exact science.  Different ovens have different power levels so what cooks in 30 seconds in one person’s microwave may take 45 seconds in someone else’s unit.  Unless you want the food to splatter all over the sides of the oven, you’ll need to cover any liquids or soft foods with waxed paper.  
    There will be days when you don’t have time to sit down at the table and enjoy a leisurely breakfast.  On these days, make a “grab-and-go” breakfast that you can take with you.  Gluten-free wraps keep for several weeks in the refrigerator and they make great fill-and-go containers on busy mornings.  Spread a wrap with peanut butter, sprinkle some fortified gluten-free dry cereal on top, then drizzle with a teaspoon of pancake syrup; roll up the wrap and you have the perfect dashboard dining breakfast to eat on the way to work.  Or scramble an egg, spoon it down the center of the wrap, and then top it off with a little salsa and pepper-jack cheese before rolling it up. If you only have three minutes before you have to leave the house, spoon some low-fat cottage cheese into a cup, stir in a dash of cinnamon, top with a little low-fat gluten-free granola or fortified dry gluten-free cereal, sprinkle berries or chopped peaches over the top, grab a spoon, and you’re ready to go!
    Smoothies can be made in literally one minute.  Toss some frozen raspberries into a blender, add a 12-ounce container of low-fat lemon yogurt, a little milk, and two teaspoons of vanilla; blend, then pour the mixture into a large plastic cup.
    If you oversleep, don’t panic.  Have some back-up foods on hand that you can grab and eat en route to work, like a gluten-free protein bar and a banana, or a bag of nuts and dried fruit, or flax seed crackers with a handful of cheese cubes, or toss some gluten-free granola over a container of yogurt and grab a spoon to take along.
    All of the above suggestions can be made in five minutes or less.  Take the time to start your day off with a healthy breakfast—you deserve to do that for yourself and for your family.
    Apple English Muffins by Connie Sarros
    This recipe is from my newly-released book Student’s Vegetarian Cookbook for Dummies.  While this isn’t a gluten-free cookbook, most of the recipes are naturally gluten-free or can very easily be converted to gluten-free.  
    Preparation time:  4 minutes.  Cooking time:  30 seconds.  Yield:  1 serving
    Ingredients:
    1 tablespoon peanut butter  1 gluten-free English muffin, toasted  1/8 large apple, peeled, cored and sliced thin ½ teaspoon butter  ¾ teaspoon brown sugar 1/8 teaspoon cinnamon Directions:
    Spread peanut butter on one toasted English muffin half.  Lay the apple slices on top. In a small microwave safe bowl, heat the butter in the microwave on high for 15 seconds.  Stir in the brown sugar and cinnamon then nuke for another 15 seconds.  Stir until smooth.  (If necessary, pop it back into the microwave until the brown sugar melts).   Drizzle the cinnamon mixture over the apple slices then place the second half of the English muffin on top. Note:  If you’re out of apples, use a pear, ripe peach or nectarine, mango, or even a banana.

    Jefferson Adams
    Can a New Gluten-Free Cricket-Flour Cookbook Turn Americans on to Eating Bugs?
    Celiac.com 08/09/2018 - Whatever one might say about crawfish, shrimp and crustaceans in general, Americans don’t typically eat bugs. Can a former Ralph Lauren marketing executive turn the world on to flour made from crickets?
    Over the last few years, Americans have been presented with a buffet of alternative proteins and meals. Robyn Shapiro’s company, Seek, has created all-purpose, gluten-free, and Paleo blended flours, which can be used cup for cup in any recipe calling for flour. 
    The company, which makes pure cricket powder for smoothies, ice creams, and other liquid-based foods, is now selling cinnamon-almond crunch cricket protein and snack bites. To get the public interested in its cricket protein and cricket flour products, Shapiro has collaborated with famous chefs to create recipes for The Cricket Cookbook. 
    The book’s cast includes La Newyorkina chef Fany Gerson, a Mexico City native known for her cricket sundaes; noted Sioux chef and cookbook author Sean Sherman; and former Noma pastry chef Ghetto Gastro member, Malcolm Livingston, among others.
    Other companies have sought to promote the benefits of insect protein, including Chapul, which makes cricket protein bars and powders, and Exo, which makes dairy- and gluten-free cricket protein bars in flavors like cocoa nut and banana bread. These companies, along with others in the business tend to aim their products at Paleo dieters by promising more protein and no dairy.
    Seek’s chef-focused approach makes it unique. By pairing with noted chefs who already use bugs and bug protein in their cooking, Shapiro is looking to make the public more comfortable and confident in using bugs to cook and bake. So far, the response has been slow, but steady. Seek has already raised nearly $13,000 from 28 backers, well on its way toward its $25,000 goal. 
    Seek’s cricket flours and other products will initially only be available via Kickstarter. If that goes well, the products will be sold on Seek’s website. Early backers will get a discount and a chance for a signed copy of the book. Seek hopes to debut their products nationwide starting in the fall. 
    Could gluten-free cricket flour and the new cookbook be the next big gluten-free Christmas gift? Stay tuned for more on this and other gluten-free stories.
    Source:
    grubstreet.com