Kenneth Miller, MD, answers questions about recognizing celiac disease and working with patients to understand the diagnosis and treatment. Kenneth Miller, MD, of board-certified gastroenterologist of New York Gastroenterology Associates, is an instructor of medicine at Mount Sinai School of Medicine. He focuses on colorectal cancer screening and developments in therapeutic endoscopy. Here, Dr. Miller addresses the diagnosis, treatment and outlook for celiac disease.
Q: Do you think celiac disease is becoming a more prevalent condition?
KM: It is not clear that the incidence is higher than in the past, but it is being diagnosed more frequently. With the rising awareness of the oligosymptomatic of celiac disease, this condition is being diagnosed more often.
Q: With the wide variety of symptoms associated with celiac disease, how should gastroenterologists approach the recognition and diagnosis of the condition?
KM: In order to diagnose celiac disease, the physician first needs to consider it as a cause for one's symptoms. With the improved ability to diagnose celiac disease we have come to realize that celiac disease can exist in a mild forms with very non-specific signs/symptoms such as fatigue, neuropsychiatric symptoms (headache, anxiety, depression, neuropathy), iron deficiency, elevated liver enzymes and premature osteoporosis. In addition, celiac disease is associated with a number of conditions such as dermatitis herpetiformis, Down's syndrome, selective IgA deficiency, type 1 diabetes, and autoimmune thyroid disease. One needs to consider celiac disease in patients with these conditions.
A patient should be screened with an IgA tissue transglutaminase antibody and a total IgA level. In those patients with a low IgA level, an IgG ttg and IgG antigliadin antibody should be tested. In those with a positive antibody, a diagnosis of celiac disease should be confirmed by obtaining duodenal biopsies. In patients with a high pre-test probability for celiac disease, I would proceed with a duodenal biopsy regardless of the test result.
Q: What are a few of the common misconceptions surrounding the disease that gastroenterologists would like to dispel?
KM: A common misconception is that celiac disease is a wheat allergy. Celiac disease is not a food allergy at all, but rather an autoimmune disorder characterized by small intestinal inflammation that occurs upon exposure to dietary gluten.
Another common misconception is that celiac disease is a "skinny person" disease. As noted above, the disease can present in an oligosymptomatic person without weight loss or malabsorption.
A final misconception is that the symptoms of celiac disease will disappear immediately upon withdrawing gluten. About 70 percent of patients will have noticeable improvement within two weeks, but a complete response often takes much longer. Symptoms generally improve faster than histology.
Q: How should gastroenterologists approach discussion of the disease with patients after diagnosis?
KM: First I discuss that celiac disease is not an allergy so that they have a better understanding that strict gluten withdrawal is important. I also discuss all of the potential consequences of untreated celiac disease, and the benefits of gluten withdrawal. I also reassure them that learning to be gluten free is a process, and that "mistakes" early on will happen and that this is not a problem in the short term. I reassure them that with time, the diet becomes part of their lifestyle and is much easier. I will also connect them with an expert dietician who can better educate them on dietary changes.
Q: Do you foresee any advancement in treatment beyond the adoption of a gluten-free diet?
KM: There are several medical approaches being studies beyond a gluten-free diet. There are drugs in clinical trials that may help prevent the breakdown of cells' tight junctions (thought to be important in the pathophysiology of celiac disease). There is another drug that is designed to try to break down the gluten molecule into nontoxic parts. An alternative approach being studied is the development of a vaccine to try to create immune tolerance to gluten.
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