Are repeated endoscopies and biopsies required for follow-up?
Most patients can be followed based on symptom resolution, improved laboratory abnormalities and declining levels of celiac disease serology.
What are the reasons for failure to respond to a gluten-free diet?
Although most patients respond rapidly to a gluten-free diet, approximately 5% do not. The primary cause of failure is continued ingestion of gluten, whether unintentional or intentional. The first step in evaluating a patient with so-called nonresponsive celiac disease is to carefully review the dietary history, usually in conjunction with an expert dietitian. Other reasons for a lack of response are conditions that complicate or coexist with celiac disease, such as lactose and other carbohydrate intolerance; pancreatic insufficiency; microscopic colitis; and small intestinal bacterial overgrowth, with or without IgA deficiency. Gastroparesis, IBS, and other forms of functional gastrointestinal disorders are common and may be postinflammatory in nature. Rarely, patients may have both celiac disease and IBD. These possibilities should be evaluated and addressed by a specialist.
When should a gastroenterologist be consulted?
Patients with serology indicative of celiac disease should be referred to a gastroenterologist for esophagogastroduodenoscopy with intestinal biopsies to confirm the diagnosis. A gastroenterologist should also be consulted for evaluation of unexplained iron deficiency anemia, chronic diarrhea, malabsorption, weight loss, and other problems suggesting celiac disease despite negative results on serology tests; these might include unexplained osteoporosis or infertility.
When should a nutritionist be consulted?
Patients with celiac disease should be referred to a registered dietitian who has expertise in celiac disease and the gluten-free diet- not all dietitians have such expertise. The gluten-free diet is challenging to both teach and learn, and very few doctors, including gastroenterologists, have the detailed knowledge on food ingredients, training, or time to effectively instruct patients.
What is the role of patient education?
Education of patients and their families is central to the management of celiac disease. Patients should understand the causes of celiac disease, the medical complications of insufficiently controlled disease, the risk for family members to develop celiac disease, and the importance of maintaining a strictly gluten-free diet lifelong.
Which patients are at risk for lymphoma?
Patients with refractory celiac disease are at greatest risk for T-cell lymphoma, and such patients, as well as those who develop new or recurrent symptoms of malabsorption abdominal pain, fever, and weight loss despite compliance with a gluten-free diet, require evaluation for potential small intestinal cancer.
Frequently Asked Questions:
Crowe. S. (2011). In the Clinic-Celiac Disease. American College of Physicians- Annals of Internal Medicine. DOI: 10.7326/0003-4819-154-9-201105030-01005