Immunology of Celiac Disease - Twitter summary from #CSACI18 meeting

Twitter summary:

Immunology of Celiac Disease with Dr M. Rash, a gastroenterologist.

Dr Rash on celiac disease- the sky is getting cloudy:

Spectrum of gluten-related disorders:

1) IgE-Mediated wheat allergy
2) Autoimmune disorders - Celiac disease
3) Non-celiac gluten sensitivity - not allergic or autoimmune

Non-celiac gluten sensitivity is still a work in progress as a diagnosis. There are symptoms similar to that of true celiac disease and can be found in DBPC trials. Blood tests and bowel biopsies show nothing. The speaker is wondering whether we should just be calling the 5-6 different names for this just being called: gluten intolerance.

Non-celiac gluten sensitivity has similar symptoms to celiac disease but lab/biopsy findings are absent. Non-celiac gluten sensitivity is associated with FODMAPs consumption, amylase trypsin inhibitor in wheat and IBS. Non-Celiac Gluten Sensitivity is a self diagnosis made by exclusion of celiac disease, perhaps their improvement is related to FODMAPs, IBS.

Most Non-Celiac Gluten Sensitivity should be renamed wheat intolerance, and many have IBS.

Celiac is derived from the latin coeliacus, from the Greek word koilakos meaning of or related to the abdomen. Celiac - root word is from Abdomen.

Gluten-containing grains: wheat, barley and rye.

Celiac disease - ingestion causes symptoms, gluten containing topical products will not exacerbate disease! Label reading is unnecessary for topical products.

Celiac disease is an autoimmune disorder with a genetic predisposition (HLA DQ2/DQ8) - it's driven by an auto-antigen against an exogenous trigger. Celiac Disease is an Auto-Immune disorder: Genetic Predisposition HLA DQ2/DQ8, Auto antigen (TTG), and Exogenous trigger (gluten). Deamidated gliadin (ingested gluten) bind HLA-DQ2/DQ8 to induce inflammation.

There may be many factors that lead to celiac disease. Children born by C-section seem to be at higher risk, presumably via microbiome changes.

Emerging new treatments for Celiac disease including zonulin antagonists that target the epithelium of the gut (Phase 2 studies). Drug development for Celiac Disease focused on Zonulin which would prevent permeability and Gliadin absorption. There are Phase II trials of vaccines against celiac disease to induce gluten tolerance.

Reviewing the pathophysiology of celiac disease- an opportunity for finding a cure:

Celiac Disease affects about 1% of the population - Prevalence varies in different regions - eg higher in North America but lower in Japan. Celiac disease is a hidden epidemic. Affects about 1% of the population but about 70% are undiagnosed globally. It is not the wheat that we are eating, cause is unknown, it is increasing similar to other autoimmune diseases.

To this day the mean duration of time to diagnosis of celiac disease is very long. It was 12 years in the early 2000’s. Six years later it was...well, still 12 years. Average time to diagnosis of Celiac remains 12 years. Clinicians: Think of other manifestations of celiac disease to help screen/diagnose early!

Some manifestations of Celiac Disease include menstrual irregularities and infertility in some patients.

The most common treatable cause of short stature in children is celiac disease. A very common early presentation of celiac disease is iron deficiency anemia.

Concordance in monozygotic twins is 70% in celiac disease. Familial risk is increased, all 1st and 2nd degree relatives should be screened. Also screen for other autoimmune disorders. Strong association between celiac disease and autoimmune thyroiditis.

IgA deficiency increases Celiac Disease risk 6 times!

Celiac Disease: the great mimicker:

It is important to recognize atypical symptoms in Celiac disease: Anemia (Iron, B12) most common presentation in adults.

Urticaria is often related to autoimmunity and celiac disease is also autoimmune. There is a 1.9 odds ratio for having CSU if you have underlying celiac disease.

Treatment of celiac disease is a strict gluten free diet for life. No food or drinks with Wheat, Rye and Barley (or their relative grains). This is not outgrown.

The celiac disease that physicians see consists only of the most symptomatic people: The Celiac Iceberg:

Gluten free diet should not be started without confirming Celiac Disease using biopsy. Gluten-free diet should NOT be started without confirming the diagnosis of celiac disease. Think Celiac - and screen. 10% of Celiac Disease patients have negative result of serological testing.

Tweets by:

Dr. Ellis @DrAnneEllis
David Fischer, MD @IgECPD
Dr. Mariam Hanna, MD @PedsAllergyDoc
Lori Connors @DrLoriConnors
Dr. A for Allergy MD @Health_Ontario_
Loubna Akhabir @lakhabir
Mary McHenry MD @maryjmchenry

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