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  • Scott Adams
    Scott Adams

    Response to NY Times Article: Confirming a Diagnosis of Celiac Disease

    I wrote this response below to address a recent New York Times article: Confirming a Diagnosis of Celiac Disease.

    Celiac.com 01/13/2010 - The problem with current diagnosis criteria for celiac disease is that it takes a certain degree of damage to intestinal villi in order to get a formal diagnosis. Since celiac disease with villi damage are just one manifestation of a much broader and more widespread problem--gluten sensitivity--many people who could still develop serious health problems if they continue to eat gluten, will go undiagnosed under the current definition of celiac disease.

    The reality of gluten sensitivity is that around 7 to 12% of the US population test positive for antibodies which are an indicator that their immune system is mounting a response to gliadin, the part of gluten that causes the reaction in those who are sensitive. Many of these people may never get flattened villi, however, many may end up with other conditions that are triggered by gluten exposure in sensitive individuals, for example nerve damage (ataxia), liver problems, diabetes, thyroid issues, etc..

    In the past 10 years the diagnostic criteria for celiac disease have been changed significantly to include various degrees of villi damage (Marsh Criteria), and as a result, more people are now being properly diagnosed. In the next 10 years I predict that blood tests alone will replace the use of all biopsy results to diagnose celiac disease, as they are a far more sensitive indicator of gluten sensitivity. Once this happens we will finally reach a point where those affected can be properly treated and avoid the risk of the many disorders that have been associated with sensitive individuals who eat gluten, some of which are described here.


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    Thank you Scott! It's so wonderful to know someone is speaking out for those who are gluten sensitive.

    Gluten sensitive sibling of a celiac.

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    Dear Scott,

    I greatly support your efforts to clarify that health problems associated with malnutrition (induced by shortened or flattened intestinal villi), are only the part of health disturbances induced and/or sustained by immune mediated reaction induced by gluten. Zorica

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    I think it's wonderful if we can get away from doing the invasive testing to confirm celiac. However, it is well known that the blood test has a high rate of false negatives (I'm living proof of that). I think the medical community needs to be more open to other types of testing to pin down this diagnosis.

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    Bravo! It is imperative the medical community replace the outdated "Gold Standard" of flattened villi for diagnosing celiac with immediate cost-effect testing which addresses the needs of today's populations to prevent further damage from occurring.

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    I really appreciated your article and the points you made in response to Dr. Crowe's article. I also posted a response to her article.

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  • About Me

    In 1994 I was diagnosed with celiac disease, which led me to create Celiac.com in 1995. I created this site for a single purpose: To help as many people as possible with celiac disease get diagnosed so they can begin to live happy, healthy gluten-free lives. Celiac.com was the first site on the Internet dedicated solely to celiac disease. In 1998 I founded The Gluten-Free Mall, Your Special Diet Superstore!, and I am the co-author of the book Cereal Killers, and founder and publisher of Journal of Gluten Sensitivity.

  • Related Articles

    Scott Adams
    The following was taken from THE SPRUE-NIK PRESS, September 1995. The University of Maryland School of Medicine sponsored a conference on July 14-15, 1995 entitled Celiac Disease: The Dark Side of the Gastrointestinal Planet, by Salvatore Auricchio, MD, summarized by Jim Lyles. Dr. Auricchio is Professor and Chairman of Pediatrics at the University Frederico II in Naples, Italy.
    celiac disease manifests itself in the small intestine. A distinct pattern of abnormalities has been observed [comments in braces have been added by Jim Lyles]:
    Villous atrophy [partial or complete flattening of the finger-like projections in the small intestine] Hyperplasia of the crypts of Lieberkuhn [the crypts under the villi become highly elongated when compared with normal crypts] Increased plasma cell and lymphocyte infiltration of the lamina propria [more lymphocytes under the epithelial or outer layer of the villi. Lymphocytes are the cells that fight off viruses, etc.] Increased intraepithelial lymphocytes [more lymphocytes within the epithelial cells. The epithelial cells form the outer layer of the intestine and allow nutrients to pass through from the intestine into the bloodstream] Abnormalities in the epithelial cells which become flattened, cuboidal, and pseudo- stratified [layered].

    Scott Adams
    Celiac.com 06/25/2003 - Below is an abstract of yet another study that supports the use of human anti-tTG type IgA serological tests to accurately diagnose celiac disease:


    Alimentary Pharmacology & Therapeutics
    Volume 17 Issue 11 Page 1415 - June 2003
    Antibodies to human recombinant tissue transglutaminase may detect coeliac disease patients undiagnosed by endomysial antibodies
    N. Tesei*, E. Sugai*, H. Vázquez*, E. Smecuol*, S. Niveloni*, R. Mazure*, M. L. Moreno*, J. C. Gomez, E. Mauriño* & J. C. Bai*
    Background: The screening and diagnosis of coeliac disease have been simplified by the advent of new serological tools.
    Aim: To assess the clinical utility of a newly developed kit for antibodies to human recombinant tissue transglutaminase (hu-anti-tTG) in a large population of patients undergoing intestinal biopsy for suspected intestinal disorders.
    Methods: We evaluated 426 serum samples from consecutive adult patients (250 from untreated coeliac disease patients and 176 from individuals in whom a diagnosis of coeliac disease had been excluded), obtained at the time of intestinal biopsy. Samples were tested for immunoglobulin A (IgA) hu-anti-tTG by enzyme-linked immunoabsorbent assay, IgA endomysial antibodies (EmA) by indirect immunofluorescence and IgA and IgG antigliadin antibodies by enzyme-linked immunoabsorbent assay. A sub-group of samples was also assessed for a guinea-pig-based anti-tissue transglutaminase.
    Results: According to the cut-off for hu-anti-tTG, the sensitivity, specificity and positive and negative predictive values were 91%, 96%, 97% and 87%, respectively. Simultaneous determination of EmA showed values of 86%, 100%, 100% and 83% for the same parameters. Although 19 coeliac disease patients (7.6%) were negative for EmA and hu-anti-tTG, both tests rendered superior statistical values to antigliadin antibody tests. At diagnosis, IgA deficiency was detected in 11 patients, but both assays were able to detect samples with mild to moderate deficiency. The comparison of hu-anti-tTG with EmA showed excellent concordance between the tests ( statistic, 0.85). Discordance was observed in 20 samples from coeliac disease patients (8%) and in nine samples from controls (5%). Fifteen samples had an EmA-negative but hu-anti-tTG-positive serology, and five showed the converse pattern. Comparison of human recombinant and guinea-pig tests showed concordant results in 96% of cases.
    Conclusions: The quantitative determination of hu-anti-tTG type IgA using a commercial enzyme-linked immunoabsorbent assay kit was highly sensitive and specific for the detection of coeliac disease. Our results in a large population of patients with a clinical condition suggestive of the disorder demonstrated that the test can be used to detect a substantial number of patients otherwise unrecognized by IgA EmA.

    Scott Adams
    Celiac.com 09/12/2006 – A recent study by researchers at Stanford University has found that barley endoprotease EP-B2 is effective at digesting gluten in rats, and should be studied further as an “adjunct to diet control” in human celiac disease patients. This new finding adds to Stanford’s growing body of work on enzyme therapy as a possible treatment for those with celiac disease, and may one day lead to a effective treatment. Effect of barley endoprotease EP-B2 on gluten digestion in the intact rat.
    J Pharmacol Exp Ther. 2006 Sep;318(3):1178-86.
    Gass J, Vora H, Bethune MT, Gray GM, Khosla C.
    Stanford University.

    Abstract:

    "Celiac Sprue is a multi-factorial disease characterized by an intestinal inflammatory response to ingested gluten. Proteolytically resistant gluten peptides from wheat, rye and barley persist in the intestinal lumen, and elicit an immune response in genetically susceptible individuals. Here we demonstrate the in vivo ability of a gluten-digesting protease ("glutenase") to accelerate the breakdown of a gluten-rich solid meal. The proenzyme form of endoprotease B, isoform 2 from Hordeum vulgare (EP-B2) was orally administered to adult rats with a solid meal containing 1 g gluten. Gluten digestion in the stomach and small intestine was monitored as a function of enzyme dose and time by HPLC and mass spectrometry. In the absence of supplementary EP-B2, gluten was solubilized and proteolyzed to a limited extent in the stomach, and was hydrolyzed and assimilated mostly in the small intestine. In contrast, EP-B2 was remarkably effective at digesting gluten in the rat stomach in a dose and time dependent fashion. At a 1:25 EP-B2:gluten dose, the gastric concentration of the highly immunogenic 33-mer gliadin peptide reduced by more than 50-fold within 90 min, with no overt signs of toxicity. Evaluation of EP-B2 as an adjunct to diet control is therefore warranted in celiac patients."

    Jefferson Adams
    Celiac.com 04/22/2013 - A recent study of celiac screening methods shows that testing for antireticulin antibodies (ARA) in patients with celiac disease is obsolete. The study includes a review of the medical literature, and recommendations for improved celiac blood screening.
    Researchers S. L. Nandiwada, and A. E. Tebo are affiliated with the Department of Pathology of the University of Utah, and ARUP Laboratories in Salt Lake City, Utah.
    Citing advances in celiac disease-specific serologic testing, Nandiwada and Tebo are calling for the elimination of ARA as a test for diagnosing celiac disease.
    People with celiac disease nearly always carry HLA-DQ2 and/or -DQ8 haplotypes, suffer from any of a range of diverse clinical presentations, including gluten-sensitive enteropathy.
    Celiac disease patients typically produce several autoantibodies, of which endomysial, tissue transglutaminase, and deamidated gliadin peptide antibodies are considered specific indicators of celiac disease.
    Although antireticulin antibodies (ARA) have traditionally been used to screen for celiac disease, these tests do not provide the best sensitivities and specificities for celiac screening.
    This review highlights recent advances in celiac-specific blood testing and supports the elimination of ARA from celiac disease screening and diagnosis.
    Source:
    Clin Vaccine Immunol. 2013 Apr;20(4):447-51. doi: 10.1128/CVI.00568-12. Epub 2013 Jan 30.

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