Numerous Clinical and Histologic Conditions Mimic Celiac Disease

Celiac.com 04/12/2021 - Celiac disease is an autoimmune disorder of the small bowel, classically associated with diarrhea, abdominal pain, and nutritional deficiencies. Rapid diagnosis of celiac disease is important, since strict adherence to a gluten-free diet can resolve most resolution of clinical and histologic manifestations of the disease. Celiac disease is commonly misdiagnosed, most often as one of these conditions.

Numerous diseases and conditions can present with clinical and/or histologic features of celiac disease. In a recent review article, a pair of researchers highlight key clinical and histologic mimickers of celiac disease.

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Many conditions that mimic celiac disease offer clues to the underlying diagnosis, and many have a targeted therapy. It is important to provide patients with a correct diagnosis, and to avoid an unnecessary gluten-free diet for non-celiac patients.

Two researchers recently set out to better understand the conditions that mimic celiac disease. Researchers Amrit K Kamboj, MD and Amy S Oxentenko, MD, are affiliated with the Department of Internal Medicine, Division of Gastroenterology and Hepatology, and the Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Minnesota, USA.

The diagnosis of celiac disease is made when there are compatible clinical features, supportive serologic markers, representative histology from the small bowel, and response to a gluten-free diet. Histologic findings associated with celiac disease include intraepithelial lymphocytosis, crypt hyperplasia, villous atrophy, and a chronic inflammatory cell infiltrate in the lamina propria.

The evaluation of a patient with serologically negative enteropathy necessitates a carefully elicited history and detailed review by a pathologist.

Medications can mimic celiac disease and should be considered in all patients with a serologically negative enteropathy.

Clinical conditions that mimic celiac disease include:

Autoimmune and/or inflammatory Conditions Can Mimic Celiac Disease

Autoimmune and/or inflammatory conditions such as inflammatory bowel disease (IBD), microscopic colitis, thyroid dysregulation, and adrenal insufficiency may all cause clinical features that mimic celiac disease, or be concurrently present in patient known to have celiac disease.

Infectious Diseases Can Mimic Celiac Disease

Infectious mimickers include giardiasis and both viral and bacterial gastroenteritis, although most viral and bacterial infections are self-limited and do not cause the chronic symptoms that can be seen with Giardia infection, unless post-infectious IBS ensues. Other chronic parasitic infections may also cause symptoms that mimic celiac disease. Other less common clinical mimickers include tropical sprue, autoimmune enteropathy, drug-induced enteropathy, Whipple’s disease, and others.

Irritable bowel syndrome (IBS) Can Mimic Celiac Disease

Irritable bowel syndrome (IBS) is the most commonly diagnosed gastrointestinal disorder, and has features that mimic celiac disease.10 Symptoms include abdominal pain along with altered bowel form and/or frequency. IBS is often associated with other disorders including somatic comorbidities.

Small Intestinal Bacterial Overgrowth (SIBO) Can Mimic Celiac Disease

Small intestinal bacterial overgrowth (SIBO) is known to cause diarrhea, bloating, and weight loss, which may mirror symptoms of classic celiac disease; SIBO may also be a cause of recurrent or refractory symptoms in a patient with known celiac disease.

The researchers divide the histological mimickers of celiac disease into early and late. The key difference being that early histologic mimickers are characterized by increased intraepithelial lymphocytes with no villous atrophy, and crypts that are either normal or have minimal hyperplasia.

Late histologic mimickers are characterized by increased intraepithelial lymphocytes, partial or total villous atrophy, crypt hyperplasia, and chronic inflammation in the lamina propria.

Early histologic mimickers include:

• Non-steroidal anti-inflammatory drugs
• Inflammatory bowel disease
• Small intestine bacterial overgrowth
• Helicobacter pylori
• Self-limited gastroenteritis
• Autoimmune conditions
• Unexplained

Late histologic mimickers include:

• Medications (olmesartan, ipilimumab, colchicine, mycophenolate mofetil, methotrexate, and azathioprine)
• Common variable immunodeficiency
• Giardia
• Crohn’s disease
• Autoimmune enteropathy
• Collagenous sprue
• Tropical sprue
• Whipple’s disease
• Enteropathy-associated T-cell lymphoma
• CD4+ T-cell lymphoma
• Unclassified sprue

Read the full report in Clin Transl Gastroenterol. 2017 Aug; 8(8): e114.