Dr. Peter HR Green MD – GIG Educational Conference – Fargo/Moorhead 2011

Dr. Peter HR Green MD
Columbia University

Gluten Related Disorders
-Celiac Disease
-Wheat Allergy
-Gluten Sensitivity (non-celiac)

Wheat allergy
-food allergy
-exercise induced wheat allergy
-contact urtica

Gluten Sensitivity
-Gluten Free product consumption has increased over time and currently is higher than low carb and low fat diet.
-only 8-12% due to celiac disease of gluten sensitivity
-not recognized as an entity by physicians
-Symptomatic response to gluten withdrawal after both celiac disease and wheat allergy excluded
-Normal biopsy
-May have positive anti-gliaden test

Mmmm. Pictures of small intestines. Villi, Epithelial cells, and microvilli. Pictures of atrophy, and inflammation.

Pathogenesis of Celiac Disease
-Wheat, Rye, Barley very closely related.
-Rice and Oats closely related to each other, but not to Wheat, Rye, and Barley.

Genetic Factors
-~10% first degree relatives
-Need HLA DQ2/8
-only accounts for 50% of genetic influence
-other genes (there are many)

Environmental Factors
-Celiac Disease in Childhood
–Breast feeding is protective
–timing of gluten introduction (later is better)
–cesarean section (increases risk)
–GI infections (increased risk)

Pathophysiology of celiac disease
-Gliadin is incompletely digested by gastric, duodenal, and pancreatic secretions.

Prevalence of celiac disease
-Common, affects about 1% of population
-about 5% in South African
-increased 4-5X in 30 years
-Finland 2.4% of elderly
-Sweden 3% children aged 12
-United States

Rate of diagnosis
-2000-2003 Doubled

The Old “CD” Epidemiology
-rare disorder typical of infancy

Modes of presentation (predominant presentation)
-0-2 years Diarrhea
-2-4 abdominal pain

-Women diagnosed 2-3X more commonly
-Exceptions children and elderly
-screening studies show about equal among genders (women go to doctor more often, men usually sicker when they are diagnosed.)

Dermatitis Herpetiformis
-Anti tTG3

Showing signs of dental enamel imperfections. Enamel is developed by age 7, and can be seen as a record of childhood health. Association between dental enamel imperfections, canker sores, and Celiac/Gluten intolerance.

-reduced bone density is common
-improves on gluten free diet
-increased fracture risk
-Drugs shouldn’t be considered as first line reflex, GF diet and calcium supplement first.

Neurological manifestations
-Peripheral neuropathy
-Exclusive of vitamin (B12,6,1,E) and copper deficiency and vitamin B6 toxicity
-suggests B6 in multi-vitamin be no more than 100% daily recommended intake

Serologic Tests in Celiac Disease
-antigliadin antibodies lgA, lgG (Not used anymore)
-Deamidated gliadin peptide (DGP) antibodies

Why Biopsy?
-Currently the diagnosis requires villous atrophy
-Why not?
-life long diagnosis requiring an expensive and restrictive diet
-some people may have + blood tests and not as yet have atrophy

-take 4-6 biopsy pieces
-chance of diagnosis increases as # of pieces are taken during biopsy
-adherence to guidelines is greater in midwest (44.6% take 4 or more)

Burden of Disease
-3% of non-celiac have autoimmune diseases
-10% of celiac have autoimmune diseases
-early diagnosis of Celiac may reduce risk of developing autoimmune diseases
-adherence to GF diet reduces risk of developing autoimmune disease

-Sources (groups)

High interest in medication.
-Older patients and men most interested
-Those with lower quality of life
-those that eat out often


Do people with celiac require increased cancer screening?
Breast and Gynocological cancer is reduced. Thyroid cancer is increased, don’t suggest any additional radiological screening. Higher in those diagnosed later in life, and those with malabsorbtion. Good physical examination that includes regular blood tests, rectal exam, and fecal exam is recommended. Colon cancer is not increased. Adhere to GF diet.

How often should children have blood test?
Recommend that children get screened. Differs based on guidelines. Do gene test using cheek swab. If they don’t have the gene, then giving them other blood tests, etc, are not necessary. Blood tests in gene positive should be done every 3-5 years. If kids are doing fine, closer to every 5 years. Kimble cheek swab.

How many people are the diagnosis tests missing?
Tests are pretty good. Maybe 15% can test negative for anti-bodies. Villous atrophy without anti-bodies and non-positive genes isn’t Celiac. Any doubt, seek a second opinion. Biopsy is retained.

I keep getting sick, and test positive for anti-bodies, is it Refractory Celiac?
If you have anti-bodies, that suggests that you are getting glutened. You’ve got to work out where the gluten is coming from. Have seen some people with very low anti-bodies that just never go away. See a nutritionist.

Is there a higher risk of auto-immune in people with gluten sensitivity?
They think that those with gluten sensitivity are less likely to get auto-immune disease. However, they are more sensitive to gluten than those with celiac. And usually don’t have anti-bodies. If anti-bodies are positive, biopsy is suggested, or possibly more pieces taken.

Alternative to drug therapy for osteoporosis?
GF diet, calcium supplement, regular bone density tests.

Enamel Hypoplasia a warning sign that children should be tested?
Yes. There can be other causes, but testing is recommended.

A little gluten once in a while ruins all your work?
Not necessarily. Accidents happen, contamination happens, etc. People on a gluten free diet reduce mortality. Cheating, purposefully eating gluten, are bad. But, accidental glutening happens.

How soon on diet before blood tests improve?
About 70% see improvement in about 1 year. Anti-bodies reduce at a rate, not all at once. So should be reducing. If still positive after 2 years, you’re still getting gluten. Should be normal at 2 years.

Necessary to use GF body products?
They think that internal ingestion is necessary. Skin products and shampoos should be ok, as long as you don’t eat them. But anything that can accidentally be ingested (e.g. lipgloss) should be avoided.

What is difference between wheat allergy and intolerance?
Allergy is immediate reaction to product. Celiac is an autoimmune response.

To receive the Celiac Disease Center’s educational materials, current research and announcements, please email Cynthia Beckman (cb2280 [at] columbia.edu) your complete contact information (Name, Address, Phone, Email)

Thank you Dr. Green!

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