CME Module 13 Celiac Disease Study Guide

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Celiac Disease and Gluten Sensitivity Study Guide Class Preparation Before class, students will be expected to review the online lecture, study guide and referenced literature. Celiac Disease Gliadin is the protein component of gluten, which is found in all wheat and many grains. Gliadin becomes deamidated by the enzyme transglutaminase into peptides. These peptides bind to HLA-DQ2 and HLA-DQ8 if they are present in the body. HLA-DQ2 and –DQ8 are present in those with celiac disease. These peptides combined with the appropriate HLAs are recognized by CD4+ T cells, triggering the secretion of interferon gamma which damages the intestinal wall. CD8+ cells do not directly recognize gliadin. Instead, they are present as a result of the inflammatory process. The CD8+ cells increase the risk of lymphoma in patients with celiac disease and continued gluten exposure. The first line for screening of celiac disease is to use serology to look for antibodies against transglutaminase and gliadin. Definitive diagnosis can be made by taking a biopsy of the small intestine. It will show diffuse eneritis with atrophic or total loss of the villi in the proximal small intestine. Studies have shown that those with celiac disease who abstain from gluten will generally recover normal intestinal architecture. Once the villi have been destroyed, it interferes with proper nutrient absorption of fats, vitamins, and even minerals. Celiac disease affects 1 in 113 Americans. It affects about 1% of the Caucasian population. Celiac disease has multiple symptoms, including diarrhea, bloating, constipation, GERD, vomiting, fatigue, muscle ache, insomnia, depression, and psychosis. Celiac disease also has a number of associated conditions, such as thyroid disease, rheumatic disease, dermatitis herpetiformis, and type 1 diabetes. The presenting symptoms are relatively non-specific and typically not present in patients newly diagnosed with the disease. Gluten Free Diet The only treatment for celiac disease is a gluten free diet. It is worth asking, though, if a gluten free diet improves the quality of life for celiac patients. It turns out that after a diagnosis of celiac disease and a switch to a gluten free diet, patients do show a reduction in risk of all-cause mortality after the first year. There is also an improvement in GI symptoms like bloating, diarrhea, and GERD. Gluten free foods can be low in fiber and minerals, and high in carbohydrates. Most patients need guidance and supplements in the first year, especially in iron, vitamin B12, and vitamin D.

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Some celiac patients wonder if they can consume a minimal amount of gluten per day, without ill effects. A review study determined that the tolerable amount of gluten varies by patient, and is somewhere between 10mg and 36mg of gluten per day. Thus a diet
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