Chapter 58: Celiac Disease

KEY CONCEPTS

• Celiac disease is a chronic, small intestinal immune-mediated enteropathy caused by intolerance to gluten found in wheat, barley, rye, and other foods when a genetically predisposed person is exposed to the environmental trigger, gluten.

• The prevalence of celiac disease is 0.7% in America and appears to be increasing in prevalence worldwide.

• The integrity of the tissue junctions of the intestinal epithelium is compromised in patients with celiac disease; this enables gluten to reach the lamina propria. The presence of gluten in the lamina propria and an inherited combination of genes contribute to the heightened immune sensitivity to gluten that is found in patients with celiac disease.

• The classic presenting symptom is diarrhea, which may be accompanied by abdominal pain or discomfort; however, it is noteworthy that during the past decade diarrhea has been reported as the main presenting symptom of celiac disease in less than 50% of cases.

• Dermatitis herpetiformis is a skin manifestation of small intestinal immune-mediated enteropathy caused by exposure to dietary gluten.

• The frequency of diagnosis of patients with celiac disease has increased; however, the majority of patients with this condition remain undiagnosed.

• The confirmation of a diagnosis of celiac disease should be based on a combination of findings from the medical history, physical examination, serology, and duodenal biopsy. The recommended serologic marker that is used for screening patients is serum antitissue transglutaminase antibody.

• Strict, lifelong adherence to a gluten-free diet is the only treatment for celiac disease that is currently available.

• Clinicians must evaluate the patient with celiac disease for nutritional deficiencies (including folic acid, vitamin B₁₂, fat-soluble vitamins, iron, and calcium) due to malabsorption.

Patient Care Process for Celiac Disease

Collect

• Patient characteristics (eg, age, sex, height, weight)

• Patient medical history (personal and family)

• Social history (eg, tobacco/ethanol use) and dietary habits including intake of gluten-containing grains (see Table 58-1)

• Current medications including nonprescription, herbal products, dietary supplements

• Objective data

  • Results of diagnostic testing (HLA typing, serology, and/or biopsy)

  • Results of testing for nutritional deficiencies (eg, iron, folic acid, vitamin D, vitamin B₁₂)

  • Results of other testing (eg, DEXA)

Assess

• Presence of signs and symptoms of malnutrition or nutrient deficiency

• Ability/willingness to follow gluten-free diet

• Ability/willingness to pay for treatment options (gluten-free food, dietary supplements)

• Emotional status (eg, presence of anxiety, depression)

• Family/caregiver support

Plan^*

• Patient education (purpose of treatment, dietary and lifestyle modification)

• Self-monitoring for symptoms of celiac disease (intestinal and extra-intestinal)

• Referral to dietician

• Dietary supplement regimen including specific anticoagulant(s), dose, route, frequency, and duration

• Medication regimen including identification of gluten-free oral medications

Implement

• Provide patient education regarding all elements of treatment plan

• Use motivational interviewing and coaching strategies to maximize adherence

• Schedule follow-up (eg, adherence assessment)

Follow-up: Monitor and Evaluate

• Resolution of celiac disease symptoms (eg, intestinal and extraintestinal)

• Patient adherence to treatment plan

• Resolution of nutritional deficiencies

• Repeat testing as needed (serology, ...