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Initial Assessment and Follow-up Care of Celiac Patients, by Peter Green, MD, summarized by Sue Goldstein

Dr. Peter Green is a gastroenterologist and the director of the GI Endoscopy Unit at Columbia-Presbyterian Medical Center in New York City. He has a large celiac patient base. On September 29th, Dr. Green spoke to the Westchester Celiac Sprue Support Group and presented an excellent review of the medical care an adult Celiac patient should receive. What follows is a summary of Dr. Greens presentation, compiled by Sue Goldstein, a past president of the Westchester group.

Initial Assessment

Dr. Green sees a lot of patients who, either through their own frustration or because of physician advice, have started a gluten-free (GF) diet without obtaining a biopsy-proven diagnosis of celiac disease (celiac disease). However, the need for a biopsy to establish a diagnosis of celiac disease must be emphasized. celiac disease is a lifelong illness with serious potential implications. In addition, sensitivity to gluten doesnt go away, and a radical lifestyle change is involved. You also need to be certain of the diagnosis because celiac patients families should be screened. The initial biopsy is also needed to serve as a baseline because one doesnt know what the future may involve.

Basic blood work is also included in the initial assessment. Such things as anemia and liver function need to be looked for. But its very important to go further than that, and knowledge of the physiology of the small intestine should lead a physician to measure those nutrients that could be malabsorbed. celiac disease involves the small intestine, where iron, folic acid, calcium, fat soluble vitamins (K, A, D, and E) and zinc are absorbed. These nutrients should be measured in the initial assessment and also during the course of the illness. Physicians will see patients who present with malabsorption of just one of these nutrients. If they are aware of the consequences of all these nutrient deficiencies, it will help them consider celiac disease as a possible diagnosis.

The patient should also have the celiac antibodies blood testing, but the diagnosis is still established on the biopsy pathology. In Dr. Greens experience, about 30% of celiacs have negative antibodies at diagnosis, so positive antibodies are not required to make the diagnosis. Antibodies testing often helps establish the need for a biopsy, but they also have great value in establishing a baseline so that an assessment can be made on how the patient is doing later on. All the antibodies should normalize, in time, when gluten is eliminated from the diet.

What about the patient who seeks a diagnosis, but has already eliminated gluten from the diet? It is very difficult for many patients to go back on a gluten-containing diet to secure a biopsy-proven diagnosis. This can often take three to six months or longer. Columbia-Presbyterian has been talking about setting up alternative means of securing a diagnosis, such as a rectal challenge. The physician can take a biopsy of rectal tissue, and then instill gliadin extract into the rectum and do a repeat biopsy a certain number of hours afterward to demonstrate an inflammatory response similar to that in the small bowel. However, interpreting the results of the gluten challenge would require a pathologist who is very experienced, and sophisticated immunology on the cells of the rectal biopsy may be needed.

Follow-up Care

Soon after diagnosis and adhering to a gluten-free diet, patients will often report an increased feeling of well-being. How well they feel--and how quickly--will also depend on what the manifestations of their disease were. For example, if the patient was iron-deficient, it will take time for the iron stores to be restored. An assessment of vitamin and mineral levels should be part of the follow-up care. Specific deficiencies need to be addressed, treated, and monitored. Patients have been seen who have been ingesting too much of the fat-soluble vitamins, with resulting problems such as liver disease (from vitamin A toxicity), and hypercalcemia (from vitamin D toxicity) which can cause confusion, constipation, and kidney problems. Certain vitamins and minerals may need to be administered, but the patient should be under a physicians guidance as to how much should be taken.

After a diagnosis of celiac disease, a bone mineral density test should be performed to assess the condition of the bones. Reports have shown that between 50-100% of people at initial diagnosis of celiac disease will have osteopenia or osteoporosis. Ostopenia is thinner bones, usually less than 2 standard deviations from normal. Osteoporosis involves an even greater deviation from normal.. In Dr. Greens experience, nearly 100% of the celiac patients at diagnosis will have osteoporosis. Surveys of celiac patients have shown an increased incidence of fractures prior to diagnosis and after diagnosis. If the bone mineral density is low, the patient should be referred to a bone mineral expert for assessment and specific individual treatment. For example, calcium and vitamin D needs will be addressed and monitored, and exercise and hormone replacement (in post-menopausal women) will be considered.

At diagnosis, patients should get a Pneumovax, because it is very common for celiacs to have poor splenic function, which puts them at risk of developing certain bacterial infections such as pneumoccal pneumonia and meningitis.

Since there is a genetic predisposition to celiac disease, another important issue in the follow-up is screening family members for celiac disease. Children and other first-degree relatives should have their antibodies status measured. About 10-15% of first-degree relatives have positive antibodies, and the bulk of the people with positive antibodies will have the disease, even though 50% of those people will be asymptomatic, even with a flat biopsy.

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What annual follow-up care should the celiac patient be getting? The most important thing is a good physical examination. Blood work, x-rays, CAT scans, mammograms and PSA tests, while valuable, do not replace a physical examination. The physical exam should include a breast exam for women, prostate exam for men, and a rectal exam for everyone. Blood work should include measurements of folic acid, calcium, and iron, and antibodies testing. Bone mineral density testing should be repeated annually for those with abnormal results, and every several years for those with normal results. Finally, patients with celiac disease should have at least one follow-up biopsy to confirm response--normalization of the biopsy sample. Patients who are non-responders, or whose clinical situation is somewhat confusing, may need more repeated biopsies at intervals.

Non-responders

What about the non-responders or people who relapse? The first thing is to check the diet with antibodies testing. People may be ingesting gluten, such as in medications, and not be aware of it. They may be getting gluten from licking stamps or envelopes. They may have misinformation from food labels or manufacturers.

However, the antibodies can normalize and the biopsy still look quite flat, so once again, the antibodies have only a limited value--but they are still important to measure. It is also important to check the original biopsy to make sure of the diagnosis. Not all pathologists are experienced enough to properly diagnose celiac disease. Pathology departments, by law, have to keep the biopsies for a lengthy period of time--some keep them for 50 years. So it is important for the physician to review the biopsy sample with a pathologist who understands the spectrum of celiac disease. The pathologist needs to know, for example, how to identify latent celiac disease and different subtle aspects of the biopsy, such as increased intraepithelial lymphocytes.

A problem that comes up in non-responders is other food sensitivities. Its very rare for people with celiac disease to also have sensitivities to other foods that result in the abnormal biopsy. There are, however, reports of ingestion of soy protein or egg or some kind of meats that cause the biopsy not to normalize.

There are other conditions that can co-exist with celiac disease and confuse physicians. For example, pancreatic insufficiency can cause diarrhea and steatorrhea (malabsorption of fat), and bacterial overgrowth can affect absorption of nutrients. Patients may have colonic pathology. Having one disease doesnt mean you cant have another disease, and other conditions need to be investigated in the celiac disease patient who is not doing well.

When there is no improvement in the biopsies, patients remain at the risk of developing or maintaining bone disease and vitamin deficiencies, and they are at a higher risk for malignancy. Patients who are refractory may need other therapies such as corticosteroids or immunosuppressent drugs such as cyclosporin. One doesnt engage in these therapies lightly (for example, steroids will thin the bones); being closely evaluated while on these drugs is important.

Prognosis for the Celiac Patient

The studies that have indicated increased mortality in celiac disease are from other countries where people have different smoking and dietary habits. It is hard to extrapolate these studies to our patient population.

Dr. Green believes existing studies indicate that the mortality rate among adult celiacs is about two to three times that of the general population, and the increased mortality is found mainly in the first five years after diagnosis. After that, the mortality rate approaches that of the normal population. That tends to suggest that it is the continued ingestion of gluten that is responsible for the increased mortality. This is especially so in regard to malignancies, where the risk of diagnosis of malignancy such as lymphoma is usually highest in the first year after diagnosis, and then decreases in incidence downward until it equals that of the normal population after about five years. There is certainly the suggestion that adhering to a gluten-free diet reduces the risk of developing a malignancy.

A Final Word--Looking For Celiac Disease

Traditionally, the incidence of celiac disease in this country, based upon epidemiological work, suggests that celiac disease occurs in about 1 in 4,600 people. Certainly its much more common than that. Serology testing of blood donors by Dr. Fasano suggests the same prevalence as in European countries, about 1 in 300 people. Dr. Green, who does a lot of endoscopies, has found an incidence of celiac disease in about 1 in 280 patients who were having endoscopies for reasons other than suspicion of celiac disease. It is important, therefore, for the gastroenterologist to have a higher suspicion for the possibility of celiac disease, and for physicians to screen for celiac disease, particularly among their patients who have associated diseases such as Insulin Dependent Diabetes, Sjogrens, and Autoimmune Thyroid Disease.

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2 Responses:

 
patricia deleon
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said this on
13 May 2008 7:16:13 AM PDT
I am a Patient of Dr. Green myself and loved him from the minute I met him. He not only is a fanstatic Dr. He has an excellent Bedside manner. I traveled , like many others 3 hours to see him and even though he was out of network with my insurance, I still was happy I saw him. He calls his patients and responses them in a matter that shocked me. I wasn't used to a doctor acting as quickly as he did . So if and when you can or do get an appointment do what he says and make sure to follow his instructions. I am confident that he will help . I have suffered for 3 years and finally felt like wow, someone understands.

 
caroline
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said this on
14 Jul 2010 2:27:23 PM PDT
Very enlightening! I wish you were in Atlanta. You shed great light over Celiac which most Doctors are not knowledgeable about! Thanks!




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Kaiser offers the full panel, but a primary care MD can not order it -- only a GI. Again, a visual is not needed. Damage is usually severe if it can be seen visually (e.g. Scalloping, etc.). Villi are microscopic though. When you got the referral, you probably should have found a GI on your own by searching through the Kaiser directory and finding one who has some mention of celiac disease in his bio. Too late, but that is kind of how it works. Your PCP does not know the GI docs. The scheduler just makes appointments. So, now, that you have been referred to a GI, you can probably schedule another appointment on your own by passing your PCP. Wait first for the pathologist's report. They might not put it on the patient portal, so get a hard copy for your records. If it is negative and they took four or biopsies, you will have your answer. Then you can consider trialing the diet. If they did not take enough samples, ask for the DGP and EMA tests, including the control test IGA deficiency (which affects 10% of celiacs, but do not quote me on this). You could wait a few years until you think damage is severe enough to find. celiac disease can be hard to diagnose. It can develop at anytime. Don't forget you might have a gluten sensitivity too and not celiac disease. Kaiser responds well to requests in writing. Try the patient portal first before a registered letter. If they are not following the standard level of care, they are at risk for a lawsuit. Be nice. Say something lame in your letter like, "We had such a nice short visit, so I forgot to ask ....blah, blah, blah." My own relatively new PCP is still learning about celiac disease. That is okay. At least she has an open mind.

It is gluten free...I eat it regularly and have had no issues and it tastes yummy. ?

A quick update: I emailed my primary doctor and she is on the same page as the GI doctor, saying the Endoscopy looks normal. Even before we've gotten the biopsy back. By the way, I should mention I'm dealing with Kaiser in the Bay Area, CA and everything I've found about Kaiser on these forums is horrible and similar to my own experience. I specifically asked about all the components of the full celiac panel and that I would like to get it and all she said was: "The lab tests are not perfect. Although they may indicate an increased risk for celiac, they are not as specific as the biopsy." So, now we should just ignore the positive IgG? How am I supposed to know if I'm IgA deficient if they don't test for that? I replied and asked again and she said that Kaiser doesn't offer the full panel. Why not? And I said I want vitamin and iron tests and no reply to that yet.

Thank you so much for all the help and support you have given me. I cannot thank you enough. I am ever so sorry to post again here but wondered if I could check with you about this. When at work, I very rarely get chance to eat a lot and so have always been eating the Milky Way UK bars, which I believe contain gluten or barley. I usually have around 6 of these as they tide me over until getting home. I also have two slices of bread on a morning. I was wondering whether this would be sufficient as I am worried in case I haven't had enough gluten? Thank you for everything and I wanted to apologise for being a nuisance on here.

Thanks Matt I appreciate your response and assistance getting " moved to my own thread" thanks so much. I do have the results of my labs they took and am unsure which labs are which so I will try to attach them and perhaps someone can help me decode them.? Thanks again Heidi