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: Unusual Manifestations of, and Conditions Associated with, CD :
: ------------------------------------------------------------- :
: by Markku Maki, MD summarized by Kathy Davis & Jim Lyles :
:.................................................................:
Dr. Maki is Professor of Pediatrics at the University of Tampere in
Finland.
The classic textbook cases of malabsorbing patients with thin, wasted
bodies, protruding bellies, and chronic diarrhea are very misleading.
Of course, such a patient may have CD. But most celiacs do not have
severe symptoms such as these.
Of the children diagnosed, few have the "classical" symptoms. In
Finland, the median age of diagnosis in children has been rising since
the 1960's, to the present level of about 7 or 8 years of age.
When a child's growth fails to follow the normal growth curves, the
possibility of CD should be investigated even if there are no other
apparent symptoms. The latest diagnostic strategy for detecting CD
includes:
1. Looking for CD even in the absence of abdominal symptoms.
2. Performing duodenal biopsies whenever gastroscopies are
performed.
3. Liberal use of serologic (blood) screening tests.
A diagnosis of CD should be considered in:
* patients with traditional symptoms, even when the symptoms are
mild or there is only one symptom.
* patients with symptoms recently recognized as being linked with
CD, such as dermatitis herpetiformis (DH), permanent-tooth enamel
hypoplasia, recurring aphthous stomatitis (mouth sores), joint
problems, arthralgia (joint pain), and arthritis.
* special cases often associated with CD, such as all first-degree
relatives of celiac patients and anyone with selective IgA
deficiency.
* associated diseases such as Down's syndrome, insulin dependent
diabetes, Sjogren's syndrome, thyroiditis, chronic liver
diseases, epilepsy, and cerebral calcifications.
There are other situations that can lead to a diagnosis of CD:
* Patients are screened with serum testing (anti-gliadin,
anti-endomysial, and anti- reticulin antibodies), followed by
biopsy.
* Patients have been diagnosed with DH and CD in the same families.
* There does seem to be a correlation between epilepsy and CD.
* A diagnosis of CD has been made in patients with so called
celiac-type dental lesions in the permanent teeth.
* CD has been diagnosed in patients with dementia [mental
deterioration brought on by organic disorders-ed.], usually young
adults with atrophy of the cerebella. (This is highly unusual.)
* Joint pain and arthralgia can be symptoms of CD.
* In diabetics, CD is often diagnosed 5-10 years after the
diagnosis of diabetes.
A hospital in Finland looked at 188 diagnosed celiac patients. Of
these, 43 (23%) showed typical malabsorption, 64 (34%) presented with
abdominal pain and mild dyspepsia, and the remaining 81 (43%) had
symptoms that were not gastrointestinal in nature.
At this point Dr. Maki began taking questions from the floor:
Q: You spoke of dental lesions. Have you come across a case where an
adult diagnosed with CD had lost his/her teeth as a child?
A: A complete loss of teeth? No.
Q: Is it possible to be IgA deficient and also have DH?
A: No. DH is caused by IgA deposits under the skin. If you are IgA
deficient you can't have these deposits. I'm not aware of any DH
patient with IgA deficiency and IgG deposits under the skin.
Q: (From Dr. Murray) Adding duodenal biopsies whenever gastroscopies
are done increases costs by about $200. How can we justify this
to insurance companies?
A: What is needed is some sort of cost effectiveness study involving
a large number of patients, to show the extent of the problem with
undiagnosed CD and how much it costs in the long term. Adding a
few hundred dollars now to this procedure could potentially save
insurance companies many thousands of dollars later. The same
line of thought can be used to justify the rather low cost of the
blood screening tests.
Q: I'm a celiac. My mother was told she had a wheat allergy as a
child, and often breaks out in hives that are different from the
pictures you've shown of DH lesions. Should she be tested?
A: I would be inclined to do a skin biopsy and look for IgA deposits,
since she is a first degree relative of a celiac.
Q: Is there any relationship between reactive airway disease and CD?
A: There is no convincing relationship.
Q: Is there any connection between CD and impaired glucose tolerance?
A: No, but the association between celiac disease and insulin-
dependent diabetes is clear.
Q: What is the connection between CD and liver problems?
A: We have a few cases where isolated liver problems were initially
observed and then CD was diagnosed. If you look at a large number
of patients with liver problems, you find a larger percentage with
CD than in the general population.
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