New Celiac Guidelines
The American College of Gastroenterology released its first clinical guidelines to help doctors diagnose and manage their patients who have celiac disease. Dr. David A. Johnson, chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, commented extensively online about the guidelines. His advice to his fellow physicians: “Beyond a little bloating and diarrhea, think outside the box. Celiac disease is grossly under-diagnosed, and we can all do better.”
Dr. Johnson provides the following synopsis of the ACG’s guidelines on celiac disease, suggesting that his medical colleagues take away these important points:
1. Antigliadin antibody testing is no longer part of celiac screening. It should not be part of a doctor’s diagnostic testing for celiac disease.
2. IgA TTG testing should now be used - but NOT for patients who are IgA-deficient.
3. In patients who are IgA-deficient, doctors need to consider other testing, such as the DGP or the IgG TTG antibody. These test strategies are available in commercial laboratories.
4. Test results (blood tests and biopsy) can be misleading if the patient has been on a gluten-free diet. For these people, genetic testing and a gluten challenge are most helpful.
5. Genetic testing (HLA-DQ2 and HLA-DQ8) is helpful in select circumstances. If the patient is HLA-DQ2 and HLA-DQ8 negative, doctos can exclude the diagnosis of celiac disease.
6. Celiac disease has a high (10%) prevalence in Down syndrome. If a patient with Down syndrome is HLA-DQ2/8 negative, doctors can dismiss the diagnosis of celiac disease.
7. When doing a diagnostic endoscopy, multiple biopsies are key to diagnosis. Doctors should now biopsy the duodenal bulb, in addition to 4 or more biopsies from the second and third portions of the duodenum.
8. In some patients, abnormal liver enzymes may be the only manifestation of celiac disease apparent on routine testing. These patients are typically very responsive to a gluten-free diet (95 percent will resolve).
9. Doctors should involve a dietitian. Celiac patients need lifelong monitoring for vitamin and micronutrient deficiencies (iron, vitamin B12, vitamin D, folate, vitamin B6, and a variety of other micronutrients, such as copper, zinc and carnitine).
Source: Celiac Disease: New Guidelines for Diagnosis and Management. Medscape. David A. Johnson, MD. August 21, 2013.