1: Examination
Patient History
When reviewing a patient's medical history and symptoms with a physician, the following areas should be considered in the discussion: (The first three are applicable to adults and children. The last is specific to children.)
- What are the symptoms? How long have they been present? How often do they occur?
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- What is the patient's emotional state? Is it consistent throughout the day? When and for how long do the symptoms occur?
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- What else is involved? Other diseases? Other organs?
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- How is the child developing?
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See What are the Symptoms of Celiac Disease? for a thorough list of possible symptoms.
Physical Examination
Depending on the presentation of symptoms, the physician will check for some of the following items:
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- hypotension (low blood pressure)
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- edema (due to low levels of protein, [albumin] in the blood)
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- dermatitis herpetiformis (skin lesions)
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- easy bruising (lack of vitamin K)
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- bone or skin and mucosa membrane changes due to vitamin deficiencies
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- protruding or distended abdomen (intestine dysmotility)
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- loss of various sensations in extremities including vibration, position and light touch (vitamin deficiency)
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- signs of severe vitamin/mineral deficiencies which may include:
- -diminished deep tendon reflexes
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- muscle spasms (magnesium and/or calcium deficiency)
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- bone tenderness and bone pain (due to osteomalacia)
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Blood Tests
There is no standardization in current tests. A number of tests, sometimes collectively referred to as the Celiac Blood Panel, will aid the physician in diagnosis. The tests may include, but are not limited to:
- EMA (Immunoglobulin A anti-endomysium antibodies)
- AGA (IgA anti-gliadin antibodies)
- DGP (Deamidated gliadin peptide antibody)
- tTGA (IgA anti-tissue transglutaminase)
- Tolerance or Measure of Digestion/Absorption Tests
- Lactose tolerance test.
- D-Xylose test.
Deamidated gliadin peptide (DGP) antibodies tests developed in 2007 in combination with Tissue transglutaminase (TTG) antibodies and have better accuracy than native gliadin antibodies. Multiplex immunoassay (MIA) measures multiple antibodies simultaneously providing with reduced turnaround time and cost. This test for antibodies is as accurate as ELISA for the presence of celiac disease. Rational combination testing can help identify patients who need intestinal biopsy.
Sensitivity/Specificity
2: Biopsy
In the event that clinical signs and laboratory tests indicate probable malabsorption, a biopsy of the small intestine [jejunal] is called for. In this test, a small flexible biopsy instrument is passed through a tube, down the throat, through the stomach and into the upper end of the small intestine where patchy, multiple snippets of tissue are gathered. The tube is removed and the tissue samples are examined under a microscope for signs of injury.
 The difference between tissue in a normal small intestine and that found in a celiac patient is remarkable. The normal finger-like projections (villi), which increase the absorptive surface area of the small intestine, are partially or totally flattened in a person with celiac disease. Enzymes located on the brush border are also drastically reduced. Lactase, the enzyme responsible for splitting milk sugar (lactose) so it can be absorbed, is an example of one of these brush border enzymes. This decrease in lactase explains why some untreated celiac patients may not be able to tolerate milk products and will have developed lactose intolerance. Elevated numbers of T-cell lymphocytes (white blood cells) are also present. The small bowel biopsy samples of persons with dermatitis herpetiformis often show similar damage.
To view a color-coded illustration of a single villus, visit MEDLINEplus.
NOTE: At this time there is no standardization in either serological testing or intestinal biopsies.
3: Diet
The diagnosis of celiac disease is complete when the health of the patient improves following implementation of the gluten-free (GF) diet. When gluten is removed from the diet, most of the damage that was done to the small intestine (the jejunum) is repaired. It takes only three to six days for the intestinal lining (the mucosa) to show improvement. Within three to six months, most symptoms subside as the mucosa returns to its normal (or nearly normal) state.
For an explanation of the gluten-free diet, see:
If, after six months on the GF diet, symptoms still persist, the following need to be considered:
- Has gluten been removed from every area of your diet and life?
(See How is Celiac Disease Treated? for information on where gluten can "hide" in food and other products.)
- Do unrelated conditions exist that are causing the continued discomfort?
(See How is Celiac Disease Treated? for information on additional conditions that may be present.)
The GF diet is a risk-free diet! Gluten, as a protein, is not essential to the diet and its amino acid components are replaced many times over by other foods. Adopting the GF diet can only result in improved health and well-being.
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