Patient Care - Allergy & Immunology - October 2007 - (Page 10)

I Celiac disease mucosa with positive serology. A type 1 lesion describes normal mucosa with increased intraepithelial lymphocytes. These lesions may be seen in first-degree relatives and in patients with no malabsorptive symptoms. A type 2 lesion is hyperplastic with increased intraepithelial lymphocytes and increased crypt depth but no reduction in villous height. These lesions are seen in celiac patients who ingest a small amount of gluten in their diet. Express Stop Lifelong adherence to a gluten-free diet is the mainstay of treatment and involves the avoidance of wheat, barley, and rye, which contain the prolamins gliadin, hordein, and secalin responsible for celiac disease. A type 3 lesion is the classic destructive lesion characteristic of celiac disease, with villous atrophy, crypt hyperplasia, and an increased number of intraepithelial lymphocytes. This classic lesion is also seen in other conditions such as giardiasis, tropical sprue, HIV enteropathy, and chronic ischemia of the small intestine. A type 4 lesion is seen in endstage and refractory disease and is characterized by collagen deposition in the mucosa and submucosa. A presumptive diagnosis of celiac disease is made when there is positive concordance of serology and biopsy results. A resolution of symptoms on a gluten-free diet serves as a definitive diagnosis for celiac disease.14 Normalization of elevated antibody titers, once the patient is on a gluten-free diet, also aids in the diagnosis. It is no longer required to make a definitive diagnosis based on a biopsy showing normalization of intestinal mucosa on a glutenfree diet. HLA typing is a useful diagnostic tool in patients with equivocal biopsies or in those on a gluten-free diet or who have negative serologic tests. A patient who lacks both the HLA-DQ2 and HLA-DQ8 haplotypes is unlikely to have celiac disease.19,20 A confirmed diagnosis of celiac disease should be followed with tests to screen for iron and folate deficiency. Bone density is important. If osteoporosis is found, measure vitamin D and parathyroid levels. Reports have shown that between 50% and 100% of patients at initial diagnosis of celiac disease will have osteopenia or osteoporosis. Prompt referral to a bone mineral specialist is recommended in these circumstances. Treatment The National Institutes of Health Consensus Development Conference on Celiac Disease outlines, via a mnemonic, the following 6 principles in the management of the disorder14: C onsultation with a skilled dietitian E ducation about the disease L ifelong adherence to a gluten-free diet I dentification and treatment of nutritional deficiencies Access to an advocacy group C ontinuous long-term follow-up by a multidisciplinary team. Lifelong adherence to a gluten-free diet is the mainstay and involves the avoidance of wheat, barley, and rye, which contain the prolamins gliadin, hordein, and secalin responsible for celiac disease. The prolamins avenin, found in oats, and zein, in corn, are not toxic to patients with celiac disease, and so these foods, along with soybeans, tapioca, and potatoes, need not be avoided. In addition to preventing both the short- and long-term complications of celiac disease, adherence to a gluten-free diet can improve symptoms of fatigue, recurrent abdominal pain, and mood changes. Associated disorders such as infertility, dermatitis herpetiformis, and ataxia usually resolve. A dietitian should evaluate the patient’s nutritional and caloric requirements and address dietary deficiencies such as iron, folate, calcium, and vitamins 10 PATIENT CARE ALLERGY & IMMUNOLOGY www.patientcareonline.com http://www.patientcareonline.com

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Patient Care - Allergy & Immunology - October 2007 Research Digest Contents Medicine in the News When to Suspect Celiac Disease and How to Proceed From There Averting Angioedema’s Potentially Dire Consequences Is There a Role for Leukotriene Receptor Antagonists in Treating Allergic rhinitis? Clinical Clips Dermatology Case Challenge Classified Advertising

Patient Care - Allergy & Immunology - October 2007

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