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2014 ; 23
(2
): 67-77
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Modern diagnosis of celiac disease and relevant differential diagnoses in the
case of cereal intolerance
#MMPMID26120517
Hahn M
; Hagel AF
; Hirschmann S
; Bechthold C
; Konturek P
; Neurath M
; Raithel M
Allergo J Int
2014[]; 23
(2
): 67-77
PMID26120517
show ga
At an incidence of 1:500, celiac disease (formerly sprue) is an important
differential diagnosis in patients with malabsorption, abdominal discomfort,
diarrhea and food intolerances. Celiac disease can induce a broad spectrum of
both gastrointestinal and extraintestinal symptoms, e.g. dermatitis herpetiformis
(Duhring's disease). A variety of oligo- and asymptomatic courses (e.g. anemia,
osteoporosis, depression) through to refractory collagenic celiac disease are
seen. In HLA-DQ2 and -8 predisposed individuals, celiac disease is provoked by
contact with wheat gliadin fractions through a predominantly Th1 immune response
and an accompanying Th2 response, which can eventually lead to villous atrophy.
Using appropriate serological tests (IgA antibodies against
tissue-transglutaminase, endomysium and deamidated gliadin peptides) under
sufficient gluten ingestion, the diagnosis can be made more reliably today than
previously. The same IgG-based serological tests should be used in the case of
IgA deficiency. Diagnosis can either be made in children and adolescents with
anti-transglutaminase titers exceeding ten times the standard for two of the
above-mentioned serological markers and HLA conformity or it is made by endoscopy
and histological Marsh classification in adults and in cases of inconclusive
serology. If clinically tolerated, gluten challenges are indicated in patients
that already have reduced gluten intake, in borderline serological results,
discordance between serological and histological results or in suspected food
allergy. The diagnosis of celiac disease needs to be definitive and robust before
establishing a gluten-free diet, since lifelong abstention from gluten (gliadin <
20 mg/kg foodstuffs), cereal products (wheat, rye, barley and spelt) as well as
from preparations and beverages containing gluten, is necessary. With effective
elimination of gluten, the prognosis regarding complete resolution of small bowel
inflammation is good. Refractory courses are seen only in rare cases, accompanied
by enteropathy-associated T-cell lymphoma.