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    Scott Adams
    Scott Adams

    Should my child have general anesthesia or conscious sedation prior to the biopsy?**

    Reviewed and edited by a celiac disease expert.

    Karoly Horvath, M.D., Ph.D., Associate Professor of Pediatrics; Director, Peds GI & Nutrition Laboratory; University of Maryland at Baltimore: The biopsy is a small piece of tissue, such as from the inside lining of the intestine, that has been removed to look for diseases. The biopsy itself is not painful, because there are no pain-sensitive nerves inside the small intestine. An intestinal biopsy can be done in either of two ways depending on the age of the children and the tradition of the institution. Sometimes a blind biopsy procedure is performed by a biopsy capsule. This is thin flexible tube with a capsule at the tip, which has a hole and a tiny knife inside the capsule. This capsule is introduced into the intestine under fluoroscopy (X-ray) control. Alternatively, with an endoscopy the doctor can see inside the digestive tract without using an x-ray to obtain biopsies. The biopsy specimens are processed and viewed under the microscope to identify or exclude celiac disease. An important basic rule is that the biopsy should be performed safely. For a safe procedure children (and adults) should be sedated. There are two methods of sedation: unconscious (general anesthesia) and conscious sedation. During both kinds of sedation the vital parameters (heart rate, blood pressure, oxygen saturation) of patients are continuously monitored. The method of choice depends on the child.

    Conscious sedation is performed with two different intravenous medications. One of them is a sedative medication (e.g. Versed), which causes amnesia in 80-90% of children, and even older children do not recall the procedure. The second medication is a pain-killer type medication (e.g. Fentanyl), which further reduces the discomfort associated with the procedure. In addition, the throat is sprayed with a local anesthetic in older children, which makes the throat numb and prevents retching at the introduction of the endoscope.



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    During general anesthesia the anesthesiologist uses sleep-gases (e.g. halothan) and intravenous medications and then places a tube into the trachea. Children are completely unconscious. This is a safer way to perform endoscopy, because the patients are fully relaxed and their airway is protected. However, the anesthesia itself has certain complications.



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  • About Me

    Scott Adams

    Scott Adams was diagnosed with celiac disease in 1994, and, due to the nearly total lack of information available at that time, was forced to become an expert on the disease in order to recover. In 1995 he launched the site that later became Celiac.com to help as many people as possible with celiac disease get diagnosed so they can begin to live happy, healthy gluten-free lives.  He is co-author of the book Cereal Killers, and founder and publisher of the (formerly paper) newsletter Journal of Gluten Sensitivity. In 1998 he founded The Gluten-Free Mall which he sold in 2014. Celiac.com does not sell any products, and is 100% advertiser supported.


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    Scott Adams
    The traditional approach to diagnosing celiac disease is a three-step process:
    Perform a biopsy of the lining of the small intestine. This is a surprisingly easy procedure which takes only a few minutes, although small children are usually sedated first, which adds to the cost and complexity of the biopsy. If the villi are damaged (flattened or atrophied mucosa), go to step 2. Place the patient on a gluten-free diet for six months or longer and then perform another biopsy. If the villi are healed, go to step 3. Put gluten back in the diet for six months or longer, and then perform a third biopsy. If the villi are again damaged, then the diagnosis is complete. At this point, the patient goes on a gluten-free diet for life. Many doctors now feel that step number three is unnecessary, and some feel that even the second biopsy may be unnecessary. Part of the reason for this change in thinking is the development of three useful antibody blood tests: endomysial, reticulin (IgA), and gliadin (IgG and IgA). If the patient has been eating gluten regularly and all three tests come back positive, there is a very high chance that the patient has celiac disease. If all three tests come back negative, then it is very likely that the patient does not have celiac disease. Mixed results, which often occur, are inconclusive.
    All of the laboratory tests that can be performed are strongly affected by a gluten-free diet. Tests will return negatives if the individual has been on a gluten-free diet for some time, and there is much debate about the length of time a patient must return to a gluten-laden diet before being tested. It probably depends on many factors: the level of damage that was done before starting a gluten-free diet, the length of time the person has been gluten-free, the amount of healing that has occurred, and the sensitivity of the individual to gluten.
    A tentative diagnosis of celiac sprue is usually offered if the patients symptoms clear up after some time on a gluten-free diet. This is often followed by a "challenge" in which one of the offending grains (usually wheat) is eaten to see if the symptoms reoccur. However, this approach is much less desirable than having a firm diagnosis from a combination of antibody tests and one or more biopsies.
    Because a gluten-free diet precludes accurate testing, if you suspect celiac disease, it is advisable to have diagnostic tests performed before starting a gluten-free diet.
    Some physicians will accept positive antibody tests, one biopsy, and improvement on a gluten-free diet as sufficient for diagnosing celiac disease. Many other doctors prefer to perform a second biopsy, feeling that if it shows normal villi after a period of eating gluten-free then the diagnosis is confirmed. There are still some doctors who prefer the three-step approach mentioned above, though most view this as unnecessary.


    Scott Adams
    No. Celiac sprue is not a well-researched disease. Most of what we know about foods that are safe and foods that are not is gathered from anecdotal evidence provided by celiacs themselves. There is a great deal of controversy about what affects celiacs and what doesnt.
    Take, for example, buckwheat. Along with corn and rice, this is one of only three common grains left on the "safe" list for celiacs. However, some celiac societies have put it on the "unsafe" list and there is anecdotal evidence that some individuals react to it as they do to wheat. Yet a well-known specialist in grain research points out that buckwheat is more closely related to rhubarb than to the toxic grains, so if buckwheat is unsafe then any plant might be unsafe.
    In considering anecdotal evidence for whether a food is safe or not, individuals must make their own choices, but each of us should clearly understand that anecdotal evidence is gathered from individuals with widely varied experience.
    It could be that the "buckwheat flour" that a celiac reacted to was actually one of those mixes that combines buckwheat flour with wheat flour. Another possibility is that, since buckwheat and wheat are often grown in the same fields in alternating years, the "pure buckwheat flour" may have been contaminated from the start by wheat grains gathered at harvest. Yet another explanation might be that the buckwheat was milled in a run that was preceded by wheat or any of the other toxic grains, so the flour was contaminated at the mill. Finally, some individuals -- celiacs or not -- may have celiac-like reactions to buckwheat; they are allergic. Celiacs who are allergic to buckwheat may be easily fooled into believing they are having a gluten reaction. Or, it could be that some evolutionary trick has put a toxic peptide chain into buckwheat despite its distant relation to the other grains, but the odds against this happening are long.
    As individual celiacs learn to live gluten-free, they must gauge their own reactions to foods, do lots of research, ask questions, and try to understand the many variables that may affect the ingredients in their food.
    The following is a list of ingredients which some celiacs believe are harmful, others feel are safe:
    Alcohol Grain alcohol Grain vinegars White vinegar Vanilla extract and other flavorings (may contain alcohol) Amaranth Millet Buckwheat Quinoa Teff   Wheat starch is used in the some countries gluten-free diet because of the belief that it contains only a trace or no gluten and that good baked products cannot be made without it. In a laboratory, wheat starch purity can be easily controlled, but in most plants this is not always the case. Wheat starch is not considered safe for celiacs in these countries: United States, Canada, Italy.
    For more information on this topic visit our Safe & Forbidden Lists.


    Jefferson Adams
    Celiac.com 02/22/2020 - We get a lot of questions about which alcoholic beverages are gluten-free and safe for people with celiac disease. The safest answer is that alcohol that is brewed or distilled using no gluten ingredients and which is labeled gluten-free is the safest bet. That said, the actual answer is more complex. 
    According to the American Dietetic Association (ADA) all distilled spirits are gluten-free, that is, there is no gluten in the final product of any distilled alcohol. ADA guidelines indicate that all 100% distilled spirits are safe, including whiskey, bourbon and gin. 
    Also, some people with celiac disease claim to be sensitive to distilled alcohols made with grains, while many tolerate them just fine. The solution is to know your alcohol. Beware of anything that seems to provoke an adverse reaction. Trust your gut and your own judgement. If you prefer whiskey and tolerate it well, then carry on. If something bothers you or upsets your stomach, then maybe consider another choice. Here are some helpful tips and some links to help you figure our which alcoholic beverages are gluten-free and gluten-safe for people with celiac disease.
    Why Are Some Alcohols Labeled Gluten-Free and Others Not?
    If all distilled spirits are gluten-free, then why do some have a gluten-free label and some do not? What's the difference?
    The main difference in the U.S. is that products labeled "gluten-free" must contain no gluten ingredients from start to finish (for distilled alcohols this ban ends on 9/14/2020). So, beer, wine, or distilled alcohol made from corn, sorghum, millet, sugarcane, rice, grapes, or anything else that doesn't contain wheat, barley or rye, can be labeled "gluten-free."
    Gluten-Free Alcohols
    Alcohols distilled or fermented from non-grain ingredients, and which contain no gluten additives or flavorings are the safest choice, as they are naturally gluten-free from start to finish. These products can also be labeled as "gluten-free." Examples include Rum, Sake, Soju, Tequila, Potato Vodka, Corn Vodka, Sorghum Whiskey, Wines, Beers brewed without wheat, rye, or barley.
    Gluten-Safe Distilled Alcohols
    Again, many people with celiac disease easily tolerate whiskey, gin, grain-based vodkas, and other alcohols distilled from grains, with no complaints. Others claim sensitivity to these products. Technically, because they are distilled, these products contain no gluten in the final product, and beginning 9/14/2020 can be labelled "gluten-free" in the United States. 
    Unsafe Non-Gluten-Free Alcohols
    Traditionally brewed Beers and Ales must be avoided, since nearly all traditional beers and ales are brewed with barley malt. Even many rice beers use malt, but there are a dozens of gluten-free beers on the market today.
    Beware of Gluten in Additives & Flavorings
    Please note, that any type of wheat, rye, or barley that may be added after distillation, such as adding some of the original mash back into the product to enhance flavor might change that equation. The same is true of things like barley malt in some wine coolers. Flavorings added after distillation can include gluten, so be careful.
    Resources for Gluten-Free and Safe Alcoholic Beverages
    Gluten-Free Alcohol - Here's our extensive list of Gluten-Free and Safe Alcoholic Beverages
    Gluten-Free Beer - Here's our Oktoberfest Beer Guide! Gluten-free vs. Gluten-removed Beers
    Gluten-Free Wine - Gluten in wine is extremely rare these days. Here's some helpful information on the subject.
    Read about or readers' personal wine experiences here.
    Gluten-Free Safe Foods and Ingredients - This list of gluten-free, SAFE foods and ingredients is helpful for knowing which foods and ingredients are safe for people with celiac disease or gluten intolerance.
    Non-Gluten-Free Unsafe Foods and Ingredients - This list of non-gluten-free, UNSAFE foods and ingredients is helpful for knowing which foods and ingredients to avoid.
    Celiac Disease & Gluten-Free Forum - Our forum is a great place to ask questions and get answers about gluten-free alcohol and other issues from real people with celiac disease. 


    Scott Adams
    The following labs have excellent reputations for such tests:
    Specialty Labs
    2211 Michigan Ave.
    Santa Monica California 90404
    Tel: 310 828-6543 or 800 421-4449
    Internet: http://www.specialtylabs.com
    The University of Maryland at Baltimore
    Attention: Karoly Horvath, MD, or Athba Hammed, Research Assistant
    School of Medicine
    Division of Pediatric Gastroenterology and Nutrition Laboratory
    UMAB/Bressler Research Building, Room 10-047
    655 West Baltimore Street
    Baltimore, MD, 21201
    410 706-1997 or fax at 410 328-1072
    University of Iowa Foundation for Celiac Disease Research
    University of Iowa Hospitals and Clinics
    200 Hawkins Drive
    Iowa City, IA 52242
    IMMCO Diagnostics, Inc.
    Vijay Kumar, Ph.D.
    IMMCO Diagnostics 
    60 Pineview Drive 
    W. Amherst, NY 14228
    Tel: (716) 691-0091 
    Toll Free Tel: (800) 537-TEST
    E-mail: IMMTEST@AOL.COM
    Immunopathology Laboratory
    Dept. of Pathology
    5233 RCP
    University of Iowa Hospitals and Clinics
    200 Hawkins Drive
    Iowa City, IA 52242
    Tel: (319) 356-2688
    Mayo Clinic
    Dr. Joeseph Murray
    Internet: http://www.mayohealth.org/mayo/common/htm/index.htm
     
    Prometheus, Inc.
    5739 Pacific Center Boulevard
    San Diego, California 92121
    Tel: (619) 824-0895
    Toll Free (888) 423-5227
    Fax: (619) 824-0896


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