Loading summary
Transcript21 lines
- [00:00]
A
Welcome back to Run the List, a medical education podcast in internal medicine. As a quick disclaimer, this podcast is made for educational and informational purposes only and should not be understood as medical advice under any circumstances.
- [00:23]
B
Welcome back to Run the List. Today we will be finishing the topic of Celiac disease with a focus on management. We are again so lucky to have Dr. Sith Sakar joining us as our expert. As you may recall, Dr. Sakar is a general gastroenterologist and newly appointed GI hospitalist at the Brigham and Women's Hospital. Sith, thank you so much for joining us again today.
- [00:45]
C
Thanks Navin. It's great to be back on the RTL podcast to conclude our discussion on Celiac disease.
- [00:51]
B
Same here, Sith. Let's go ahead and run the list. So to recap our last episode, you saw a 34 year old healthy female with a history of iron deficiency anemia presenting with bloating, a change in her stool quality and fatigue. Her family history was notable for type 1 diabetes in her mother. On exam you noted skin pallor and a mildly distended abdomen with hyperactive bowel sounds and slight tenderness in the upper abdomen. Initial labs returned with a mild microcytic anemia with a hemoglobin of 11 grams per deciliter and a TTG IgA that was significantly elevated at 500 units per milliliter. You proceeded to an upper endoscopy and duodenal biopsies confirmed the presence of Celiac disease. Sith, when you see this patient follow up with now confirmed Celiac disease, how do you begin counseling the patient about management?
- [01:41]
C
Yeah, that's excellent question. This is now the second part of this where now they have the confirmed celiac disease. So the most important thing is to start talking about a gluten free diet and the main sources that I mentioned are things like wheat, rye and barley and this can be a very big major lifestyle change, especially compared with the western diet. It's really important to read all nutrition labels and pay attention to any additives, especially because gluten can be snuck in into anything. A big alcoholic drink that people need to start avoiding is no beer unless it clearly is marked as gluten free. But again you have to really pay attention to the labeling and then you have to be careful with oats because they are also often cross contaminated with gluten. I actually often upfront really advise and refer people to nutrition for additional support because they can really walk people through their diets and big sources of gluten and how to avoid it and I found that that's very helpful, especially upfront when the diagnosis of celiac disease is made.
- [02:41]
B
That's great, Seth. So I know this comes up often, especially with patients who are asymptomatic and found to have celiac disease. What do you do if your patient asks if it is okay to have gluten every now and then?
- [02:53]
C
Yeah, this comes up almost every time, especially if they're asymptomatic. You know, there's a whole host of micronutrient deficiencies that can develop and we'll get into that a little bit later. But the biggest thing that I counsel them on especially is the development and the small risk of lymphoproliferative disease and small intestinal lymphoma that can develop if there's continued exposure to gluten, even if they're asymptomatic. And you, you know, this is pretty rare, but you know, it can be profound when it does develop. So it's important for patients to understand this. And that's why we really harp on the gluten free diet, because that's really our biggest management for celiac disease currently.
- [03:31]
B
Got it. So you always advise a strict gluten free diet. And once the patient has made this lifestyle change, when and how do you assess their response to the gluten free diet?
- [03:42]
C
Yeah, it first starts with repeat serologic testing, especially the tissue transglutanase, especially if they didn't have any issues with IgA deficiency or anything beforehand. And I get that at the 6 and 12 month mark. It's really only helpful if it was elevated at the time of diagnosis. And now the second step that I do is I do repeat endoscopy on them with repeat biopsies of the duodenum to ensure that there's mucosal healing. This is typically around the one year mark. I don't typically do it sooner than the one year mark. They need to be on a strict gluten free diet for at least a year. And then also ideally, the serologic testing would be normalized prior to proceeding with repeat endoscopy.
- [04:21]
B
Perfect. So in addition to specifically monitoring the response of the celiac disease to therapy, what other items do you need to manage?
- [04:30]
C
Yeah, like mentioned above, I think the biggest things are nutritional deficiencies. And these are labs that I send off at the time of diagnosis, any fat soluble vitamins, so A, D, E, vitamin k, and using PT as a potential marker for that, PTINR, vitamin B12, folic acid and then iron studies as well. Are all can develop, especially in any patient with celiac disease and important to monitor while we go along. And then I also get a DEXA at the time of diagnosis because people can develop bone loss with this. And the other thing is important is vaccination and pneumococcal vaccine is recommended because there's an association with hyposplenism. So those are the biggest things that you know, looking for monitoring and the response of celiac disease therapy.
- [05:15]
B
That's great.
- [05:16]
C
So, yeah, there is, you know, there
- [05:17]
B
is a lot to review beyond just following a gluten free diet. And this is why I find it's helpful for patients with celiac to actually establish themselves with the GI provider who can counsel them not only on the gluten free diet, but also check for all of these other potential abnormalities that you mentioned really nicely just there. So is there anything else, Seth, you recommend to your patients who have been newly diagnosed with celiac disease?
- [05:44]
C
Yeah, one of the things that can sometimes go amiss, but it's important to keep in mind is to screen any first degree family member, even anyone that's asymptomatic for celiac disease, just because there's such a huge genetic relation with it. So it's important to screen all first degree family members for it. And then that way you can pick up any risk of micronutrient disease, bone loss, and then the small risk of malignancy as we had mentioned before.
- [06:08]
B
Excellent, Seth. That was a fantastic review. One last question before we conclude. What about the individuals who start a gluten free diet but do not respond, that is they have persistent serologic and or histologic abnormalities consistent with celiac disease.
- [06:24]
C
Yeah, we do run into this quite a bit. You know, typically the vast majority are either non adherent or they are trying to be adherent and they have unknown gluten ingestion. So I talk about cross contamination, especially in the kitchen and then really reading those labels. And this is where nutrition referral can be very helpful as they can go through your diet making sure there's no cross contamination, making sure there's no unknown gluten ingestion because this can really, you know, affected and as we talked about, there's so many risks associated with it and keep those neurologic values high. So that's where I start with. There's other less common situations that can happen. And this includes sort of having concurrent disorders such as SIBO or lactose intolerance. And a big one that you want to watch out for is microscopic Colitis, sort of masquerading as well. And, you know, people should get a colonoscopy with biopsies to sort of rule this out. If people are having sort of persistent diarrhea or other things with celiac disease, a very rare case, you know, if you rule out that they're being very adherent, that there's no cross contamination, there's no other concurrent disorder that's happening is refractory sprue. And there's two types of it, type one and type two. And it requires sort of histologic diagnosis from that. And sometimes patients do require steroids for this and even stepping up to immunomodulator therapy. It's very rare, but it is something that I always keep in the back of my mind.
- [07:46]
B
That was great, Seth. So thank you so much for taking us through the key parts of managing celiac disease beyond just the recommendation to start a gluten free diet. So before we leave, can you leave us with some RTL pearls from today's episode?
- [08:00]
C
Absolutely. I think the biggest things to take away would be that it's important to check the response to gluten free diet after you've made the diagnosis of celiac disease. And you do this with both serologies as well as repeat duodenal biopsies. Important to keep in mind other potential complications including micronutrient deficiencies, bone loss and hyposplenism. Make sure people are getting the vaccines that are needed, the labs that they're needed to sort of monitor this. And then most importantly, do not forget to recommend screening of all first degree relatives so that people get diagnosed and caught earlier so that they're managed well.
- [08:35]
B
Amazing. Thank you so much, Sith. We had a great time discussing how to manage celiac disease and I definitely look forward to having you back for another episode very soon.
- [08:43]
C
Thank you so much. Niven.