Continuing Education Activity

Celiac disease, also known as gluten-sensitive enteropathy, is an autoimmune disease of the small intestine in which the body responds to gluten with an inappropriate immune response, causing small intestinal inflammation and damage. This activity illustrates the evaluation and management of celiac disease and reviews the role of the interprofessional team in improving care for patients with this condition.

Objectives:

• Review the pathophysiology of celiac disease.

• Apply best practices when treating a patient with celiac disease.

• Apply best practices when evaluating a patient suspected of having celiac disease.

• Improve care coordination among interprofessional team members to improve outcomes for patients affected by celiac disease.

Introduction

Celiac disease is an enteropathy of the small intestine. It is triggered by exposure to gluten in the diet of susceptible people. The susceptibility is genetically determined. The condition is chronic, and currently, the only treatment consists of permanent exclusion of gluten from the food intake.[1][2][3]

Patients with celiac disease can present with diarrhea and failure to thrive; some may be asymptomatic.

Etiology

The symptoms of celiac disease are due to the damage of enterocytes in the small intestine. In the full-blown clinical picture, the typical features of the small intestine are chronic inflammation and villi atrophy. [4][5][4]

An individual has to have HLA-dominant DQ2 or DQ8 genes. The disease results from the immune system reacting adversely to gluten, and one of the important proteins involved is an antibody to tissue transglutaminase. However, other pathways have been proposed that contribute to the disease. The glycoprotein gliadin (present in gluten) has a direct toxic effect on enterocytes by up-regulating the production of IL-15.

Some studies indicate that gastrointestinal infections in early childhood are relevant to developing celiac disease later in life. This is not surprising considering the organ affected, but likely that is also directly relevant to the fact that a disorder of immune function causes celiac disease.

IgA antibodies to smooth muscle endomysium and tissue transglutaminase are often used to diagnose celiac disease. However, only about 5% of patients with celiac disease have a deficiency of this immunoglobulin.

Epidemiology

The prevalence of celiac disease in the general population is about 0.5 % to 1%. Both true prevalence, as well as detection and diagnosis, have increased over the past 10 to 20 years. The incidence is greater among people with autoimmune disorders like type 1 diabetes. In first-degree relatives of people affected by celiac disease, the risk is 1 in 10.

Pathophysiology

A peptide derived from gluten called gliadin causes damage to the small intestine. There is local inflammation, and the process leads to the destruction of the small intestinal villi. This destruction, in turn, leads to the decreased functionality of the intestinal surface and malabsorption. The lack of nutrient absorption directly impacts the digestive system and indirectly affects all body systems. This impact results in generally poor health and is the reason why celiac disease can have signs and symptoms arising from almost any system of the body, not just the gastrointestinal system.[6]

Histopathology

Celiac disease only involves the mucosa of the small bowel. The villi may be absent or atrophic, and crypt hyperplasia may be present. An increased proliferation of lymphocytes and plasma cells is seen in the lamina propria.

Toxicokinetics

There has been long-standing doubt about the toxicity of oats for a patient with celiac disease. Recently, studies have shown that oats are not harmful. Any doubts were likely because oats are commonly processed together with wheat, and therefore, cross-contamination was very high.

History and Physical

The common symptoms are lethargy and diarrhea, hence the name celiac sprue. Other gastrointestinal symptoms are abdominal distension, discomfort or pain, vomiting, and constipation. In childhood, failure to thrive is an important aspect of history, while in adulthood, the corresponding symptom would be unexplained weight loss. Symptoms other than gastrointestinal systems include recurrent aphthous ulcers in the mouth, iron deficiency anemia, ataxia, chronic headaches, and delayed menarche. The incidence of some obstetric complications, such as preterm labor, growth restriction, and stillbirth in women with untreated celiac disease, is higher.

Dermatitis herpetiformis is a skin condition caused by gluten intolerance, and like enteropathy, it usually responds to the exclusion of gluten from the diet.

Extraintestinal symptoms are common and may include:

• Anemia due to defective absorption of vitamin B12, folate, or iron
• Coagulopathy due to impaired absorption of vitamin K
• Osteoporosis
• Neurological symptoms like muscle weakness, paresthesias, seizures and ataxia

Evaluation

Diagnostic workup usually starts with serological tests. The 2 antibodies measured are anti-tissue transglutaminase antibodies (by enzyme-linked immunosorbent assay or ELISA measured numerically) and anti-endomysial antibodies that are usually reported as negative, weakly positive, or positive. Traditionally, the next step and the gold standard for the diagnosis is duodenal mucosal biopsy; this shows villous atrophy in celiac disease. These tests must be performed while the patient is on a regular, gluten-containing diet.[7][8]

Another useful test is for human leukocyte antigen (HLA). Specific HLA genotypes have been strongly associated with celiac disease. HLA testing can be used in the diagnostic process. For example, Joint BSPGHAN and Celiac UK guidelines published in 2013 indicate that positive serological tests with positive HLA typing in the presence of typical symptoms can be accepted as confirmative of diagnosis without needing biopsy.

Laboratory Studies

• Both type 1 diabetics and Down syndrome have a high incidence of celiac disease, so appropriate workup is required.
• Electrolytes may reveal hypocalcemia, hypokalemia, and metabolic acidosis.
• Anemia due to folate, iron, or Vit B12 deficiency may be observed.
• Prothrombin time may be prolonged.
• Stools are greasy and have a rancid odor.

Radiology

Small bowel follow-through may reveal obliteration of intestinal mucosa, bowel dilatation, and flocculation of the barium.

Upper endoscopy is often used to confirm the diagnosis.

Treatment / Management

It is recommended that all people diagnosed with celiac disease follow a strict gluten-free diet. This adherence is best accomplished under the supervision of specialists, including a dietician. In general, symptoms improve on the gluten-free diet within days to weeks. Unresponsive patients need further review of the diagnosis but also an assessment of compliance with the diet. Serology testing can assess compliance. Non-compliance can be unintentional in an individual still ingesting gluten without realizing it.[9][10]

Other tests include looking at the impact of malabsorption (due to celiac disease). The following can be monitored: complete blood count, iron stores, folate, ferritin, levels of vitamin D and other fat-soluble vitamins, and bone mineral density.

Management of patients with positive serology but no abnormal findings on biopsy on duodenal biopsy is controversial. There are many situations when the diagnosis is not clear-cut. Some patients experience relevant symptoms despite no identified changes on small gut biopsy. There is also seronegative celiac disease. This term describes the reverse situation when, in spite of typical symptoms, there is no serological evidence of the disease, but there is significant villous atrophy of duodenal biopsy.

Currently, the only recommended treatment for celiac disease is a gluten-free diet. This significantly impacts the lives of people affected and can be challenging to maintain. Continuous work is being conducted on possible nondietary therapies that enable people with celiac disease to tolerate gluten. One of the main focuses of the research in this area is immune modulators. Other approaches, like immunizations or ingesting substances that would change the toxicity of gluten, are also being explored. However, none have reached the stage of being recommended or approved for such therapy.

Corticosteroids only benefit a small percentage of patients with celiac disease.

Differential Diagnosis

• Bacterial gastroenteritis
• Crohn disease
• Giardia
• Irritable Bowel syndrome
• Malabsorption
• Viral gastroenteritis

Prognosis

The prognosis for patients with the correct diagnosis and treatment is good. Unfortunately, compliance with a gluten-free diet is very difficult, and relapses are common. Some patients do not respond to a gluten-free diet or corticosteroids; they have a poor quality of life.

Complications

In the long run, there is a risk of lymphomas and adenocarcinomas of the small bowel. Pregnant women may have a miscarriage and/or have an infant with congenital birth defects. Short stature and failure to thrive can occur in children.The inabilityy to absorb the nutrients can lead to the following:

• Osteopenia
• Bleeding diathesis
• Stunted growth
• Anemia
• Lack of exercise endurance
• Seizures

Postoperative and Rehabilitation Care

Once the diagnosis of celiac disease is made, patents need regular follow up to ensure that they are compliant with a gluten-free diet and not developing any complications.

Deterrence and Patient Education

Patient should remain compliant with a gluten-free diet

Pearls and Other Issues

Untreated celiac disease leads to chronic ill health and complications. Secondary lactose intolerance is common. There is increased the risk of osteoporosis, epilepsy, infections and bowel cancer and jejunal lymphoma. Lack of calcium leads to problems with dentition.

Because celiac disease is an autoimmune disease, many clinicians recommend that all patients with celiac disease should also be screened for type 1 diabetes and thyroid function problems. This screening is recommended because similar autoimmune disturbances are at the root of these disorders. Therefore, there is an increased risk of these disorders in people who share a common genetic background.

Enhancing Healthcare Team Outcomes

The number of cases of celiac disease has gone up in the last three decades. The disease is initially often mistaken for irritable bowel syndrome, and the diagnosis is delayed for months or years. Celiac disease can have significant complications if it is not treated, and hence, an interprofessional team approach to diagnosis and treatment is necessary. Most patients initially present to the nurse practitioner, pediatrician, or primary care provider with complaints of diarrhea and abdominal pain.

If the disorder is suspected, a gastroenterologist should be consulted. Once the disease is confirmed, patients are generally managed as outpatients. Nurses play a vital role in monitoring these patients for complications and compliance with the diet. A dietary consult is highly recommended, as these patients need to know the importance of a gluten-free diet.

Further, children must be monitored for stunted growth and failure to thrive.[11][12] 

Several national guidelines have recommended an interprofessional approach to celiac disease as it can involve many organs in the body. New evidence reveals that these patients may be prone to a high rate of fractures, and hence, bone scanning should be performed.

Comprehensive nutritional management is required with an interprofessional approach to treatment. The nurse should monitor patients for refractoriness to treatment because these patients may require corticosteroids. In addition, all healthcare workers who look after celiac patients should be aware that the disorder can cause lymphomas and adenocarcinomas of the intestine at some point. Further, celiac disease is also associated with psychiatric illness, depression, and infertility.[13] 

Outcomes

The prognosis for patients who are diagnosed early and remain compliant with their gluten-free diet is excellent. However, some patients do not respond well to a gluten-free diet, and they may require steroids. The prognosis for these patients is guarded.[14][15]