Celiac Disease Statistics, Diagnosis, and Management

The World Gastroenterology Organization describes the prevalence of celiac disease as a “statistical iceberg” in today’s health climate. The tip of this iceberg represents only diagnosed cases; many more undiagnosed cases lie below the surface. Also known as “sprue” or simply “celiac,” the condition is more common than previously thought. There has been an increase in confirmed diagnoses over the past 20 years. Understanding the risk factors, associated morbidities, symptoms, diagnosis, treatment, and management of celiac disease is essential for convenient care providers on the frontlines of the health care system.

Gluten is a protein found in foods containing wheat, rye, and barley, as well as various other foods and products. These products include certain nutritional and herbal supplements, OTC and prescription medications, lip balms or glosses, toothpastes, mouthwashes, and other skin care products. Hidden sources of gluten may also be found in malt favoring, modified food starch, stabilizers, and preservatives. Celiac disease is an autoimmune genetic intolerance to gluten that can occur at any age. The gluten causes damage to the small intestine, resulting in atrophy of the villae. This atrophy causes the inability to absorb essential nutrients, causing a host of health issues.

Symptoms of celiac disease can be both intestinal and extra-intestinal. Intestinally, patients may complain of diarrhea, atulence, bloating, nausea, and stomatitis. Extra-intestinally, patients may present with weight loss, iron

deficiency anemia, low bone density, and depression, and children may fail to thrive. Interestingly, the presence of dermatitis herpetiformis is pathognomonic for celiac disease. In 80% of these cases, the patient is otherwise asymptomatic. Dermatitis herpetiformis is characterized by a pruritic, papulo-vesicular rash typically found on elbows, knees, buttocks, and the back of scalp, and it is triggered when a gluten-containing product is ingested.

Celiac, like most autoimmune diseases, is more common in women. Other risk factors for developing the disease include having a first- or second-degree relative with celiac disease, having other autoimmune disorders (including insulin-dependent diabetes and immunoglobulin A deficiency), and having Down syndrome. Diagnosis is made first through serologic testing and, ultimately, a small intestine tissue biopsy for confirmation.

The incidence of the disease varies globally. In the United States, 1 in 100 to 200 individuals has it, whereas in Japan, the incidence is as low as 1 in 20,000 individuals. By contrast, Kuwait has a very high incidence, with 1 in 18 having the disease. Some study results have suggested that disparities in diagnosis globally account for these differences; however, there are no evidential studies to explain this disparity.

In recent years, many people have come to believe they have a gluten sensitivity, which has resulted in an increased demand for gluten-free products. It is not clear if these individuals are trying a gluten-free diet to lose weight or if they believe this diet will reduce overall physical in inflammation. There are no valid studies to prove either of these theories. Medical professionals caution against initiating a gluten-free diet trial as a means to rule in celiac disease. The removal of gluten from the diet can improve symptoms of irritable bowel syndrome and acid reflux, thus confounding the diagnosis. Differential diagnoses include

nonceliac gluten sensitivity, giardiasis, autoimmune enteropathy, and eosinophilic gastroenteropathy.

Treatment is a lifelong gluten-free diet. In some refractory cases, patients may be placed on immune-modulators or steroids. The CDC has produced a mnemonic device for patients and providers for the management of celiac disease:

C

onsultation with a registered dietician,

E

ducation,

L

ifelong gluten-free diet,

I

dentification of nutritional deficiencies,

A

ccess to advocacy groups, and

C

ontinuous, long-term follow-up.

We, as convenient care providers, are poised to aid in the identification of potential risks for and symptoms of celiac disease in the patients we see every day. We can help our patients by teaching them to read labels, and foods that are well tolerated without gluten, and become educated on the

CELIAC

lifestyle.

Mary McCormackisa practicing family nurse practitioner in New Jersey as well asa field educator forMinuteClinic. She has been practicing as a family nurse practitioner for 23 years primarilyin family practice andconvenient care. Shereceived her BSN from Georgetown University and her MSN and MPH from Columbia University in FNP and population and family health programs.

References

1. Pelkowski T, Viera A. Celiac disease: diagnosis and management.Am Fam Physician.2014;89(2):99-105.
2. Pietzak M. Celiac disease, wheat allergy, and gluten sensitivity: when gluten free is not a fad.JPEN J Parenter Enter- al Nutr.2012;36(suppl 1):68S-75S. doi: 10.1177/0148607111426276.
3. World Gastroenterology Organisation. WGO practice guideline — celiac disease. WGO website. worldgastroenterology.org/guidelines/global-guidelines/celiac-disease. Accessed January 5, 2016.