Celiac Sprue

GENERAL PRINCIPLES

• Celiac sprue consists of chronic inflammation of proximal small bowel mucosa from an immunologic sensitivity to gluten (protein found in wheat, barley, and rye), resulting in malabsorption of dietary nutrients.

• Clinical presentation can vary greatly from asymptomatic iron deficiency anemia to significant diarrhea and weight loss. Other presenting features can include osteoporosis, dermatitis herpetiformis, abnormal liver enzymes, and abdominal pain; incidental recognition at endoscopy can also occur.¹⁰⁰

• More than 7% of patients with nonconstipated IBS have celiac-associated antibodies, suggesting that gluten sensitivity may trigger symptoms resembling IBS.¹⁰¹

DIAGNOSIS

• Noninvasive serologic tests are highly sensitive and specific and should be checked while the patient is on a gluten-containing diet. Both IgA anti-tissue transglutaminase (TTG) and antiendomysial antibodies have accuracies close to 100%. Quantitative IgA levels should also be checked; IgG antibodies against TTG are checked if the patient is IgA deficient.¹⁰¹

• EGD with small bowel biopsies is performed to confirm diagnosis with positive serologic testing or if suspicion remains high despite negative noninvasive testing. Classic biopsy findings include blunting or absence of villi and prominent intraepithelial lymphocytosis.

• Almost all patients with celiac sprue carry HLA-DQ2 and HLA-DQ8, so absence of these alleles has high negative predictive value when the diagnosis is in question or if patients are on a gluten-free diet.

• Nonceliac gluten sensitivity should only be considered after exclusion of celiac disease with appropriate testing; differentiation is important for risk identification for nutrient deficiency, complications, and family member risk.

TREATMENT

Medications

• Patients may require iron, folate, vitamin D, and vitamin B₁₂ supplements.

• Corticosteroids (prednisone, 10-20 mg/d) may be required in refractory cases once inadvertent gluten ingestion has been excluded; immunosuppressive drugs have also been used.¹⁰²

Lifestyle/Risk Modification

• A gluten-free diet is first-line therapy and results in prompt improvement in symptoms. Dietary

nonadherence is the most frequent cause for persistent symptoms.

• If symptoms persist despite a strict gluten-free diet, radiologic and endoscopic evaluation of the small bowel should be performed to rule out complications including collagenous colitis and enteropathy- associated T cell lymphoma. However, the prognosis of adults with unrecognized celiac disease is good despite positive celiac antibodies; therefore, mass screening appears unnecessary.¹⁰¹