Edit concept Create issue ticket

Celiac Disease

Coeliac disease (celiac sprue, nontropical sprue, endemic sprue, gluten enteropathy) is a chronic autoimmune disorder of the small intestine that results in an inability to tolerate gliadin, a prolamin found in wheat. Symptoms include pain, chronic constipation, chronic diarrhoea, failure to thrive and fatigue.


Presentation

Diarrhea is the most common symptom in untreated celiac sprue and is present in 45-85% of all patients. Diarrhea caused by celiac disease is due to the maldigestion and malabsorption of ingested nutrients. The stools might be watery or semiformed, light tan or gray, and oily or frothy and have a characteristic foul odour. In infants and young children, extensive diarrhea often leads to severe dehydration, electrolyte depletion, and metabolic acidosis [6].

Malabsorption of ingested fat (steatorrhea) results in the delivery of excessive dietary fat to the large bowel. This results in the production of hydroxy fatty acids by bacteria, which causes secretion of fluids into the intestine. Flatulence (seen in 28% of patients) and borborygmus (seen in 35-72% of patients) results from the release of intestinal gas by the bacterial florae feasting on undigested and unabsorbed food materials and often becomes excessive and in some cases, explosive.

Weight loss (seen in 45% of all patients) is variable because some patients might compensate for the malabsorption by increasing food intake. In infants and young children with untreated celiac disease, failure to thrive and growth retardation are relatively common.

Anemia (seen in 10-15% of patients) is usually due to impaired absorption of iron or folate from the proximal small intestine. In severe celiac disease with ileal involvement, absorption of vitamin B-12 might be impaired. A bleeding diathesis is usually caused by prothrombin deficiency due to impaired absorption of fat-soluble vitamin K.

Osteopenia and osteoporosis might cause bone pain for several reasons, including defective calcium transport by the diseased small intestine, vitamin D deficiency, and binding of luminal calcium and magnesium to unabsorbed dietary fatty acids.

Easy Bruising
  • […] diet is commenced Weight loss Chronic constipation – some are more likely to experience constipation rather than diarrhoea Flatulence and abdominal distension Cramping and bloating Nausea and vomiting Osteoporosis (thin bones) Less common in adults: Easy[coeliac.org.nz]
  • The decreased ability to digest, absorb, and utilize food properly (malabsorption) may cause anemia (low red blood count ) from iron deficiency or easy bruising from a lack of vitamin K.[medical-dictionary.thefreedictionary.com]
Anemia
  • This cross-sectional analytical study was conducted among children aged 1 to 12 years of age with moderate-to-severe iron deficiency anemia and control children without anemia.[ncbi.nlm.nih.gov]
  • Celiac disease may present with hematological abnormalities including long-standing anemia. Both aplastic anemia and celiac disease have a similar underlying autoimmune process but an association between the two is seldom reported.[ncbi.nlm.nih.gov]
  • After seeing his primary care physician, he was diagnosed with anemia which was attributed to the epistaxis. After being evaluated by an ear, nose, and throat (ENT) specialist for treatment of the epistaxis, anemia continued.[ncbi.nlm.nih.gov]
  • Anemia is common in patients with celiac disease (CD) and a frequent mode of presentation. Guidelines recommend screening patients with iron-deficiency anemia (IDA) for CD. However, the reported prevalence of CD in patients with IDA varies.[ncbi.nlm.nih.gov]
  • Gluten enteropathy (celiac disease) is a chronic disease and presents as diarrhea, weight loss and anemia. A 35-year-old Caucasian man with gluten enteropathy, familial multiple lipomas and seborrheic keratosis was seen in our clinic.[ncbi.nlm.nih.gov]
Weight Loss
  • This article describes a toddler who initially presented with recurrent diarrhea and weight loss with a significant secondary hypokalemia. His initial examination included screening for celiac disease, but the serology was negative.[ncbi.nlm.nih.gov]
  • Gluten enteropathy (celiac disease) is a chronic disease and presents as diarrhea, weight loss and anemia. A 35-year-old Caucasian man with gluten enteropathy, familial multiple lipomas and seborrheic keratosis was seen in our clinic.[ncbi.nlm.nih.gov]
  • A 61-year old man with coeliac disease and chronic lack of appetite, malabsorption and weight loss, despite the gluten-free diet, was operated because of a sub-diaphragmatic free air due to a small-bowel pneumatosis cystoides intestinalis (PCI).[ncbi.nlm.nih.gov]
  • A large clinical spectrum of manifestations accompanies the onset of the disease with diarrhoea, flatulence and weight loss being the most common.[ncbi.nlm.nih.gov]
  • Symptoms included abdominal pain, diarrhea and weight loss. Laboratory tests showed reduced IgM, DQ2-HLA and negative anti-transglutaminase. Villous atrophy and diffuse immature lymphocytes were observed at histology.[ncbi.nlm.nih.gov]
Fatigue
  • Our patient presented to clinic with complaints of a burning tongue for the past two years as well as occasional loose stools and fatigue. Work-up revealed iron deficiency anemia, zinc deficiency and an abnormal celiac panel.[ncbi.nlm.nih.gov]
  • Bilateral non traumatic femoral neck fatigue fracture is a rare condition usually occurring secondary to medical conditions such as pregnancy, pelvic irradiation, corticosteroid exposure, chronic renal failure and osteomalacia.[ncbi.nlm.nih.gov]
  • The most frequent extra-intestinal symptoms were fatigue, stress, and anxiety. In addition, 6/13 participants had bronchial asthma.[ncbi.nlm.nih.gov]
  • Avoidance of gluten is critical for individuals with celiac disease (CD), but there is also concern that "extreme vigilance" to a strict gluten-free diet may increase symptoms such as anxiety and fatigue, and therefore, lower quality of life (QOL).[ncbi.nlm.nih.gov]
  • If you are experiencing shortness of breath, fatigue, nausea, pressure in your chest, or gastric pain, seek emergency care.[prevention.com]
Malnutrition
  • Neurological symptoms were preceded by two months of gastrointestinal symptoms such as vomiting, abdominal distention, and clear signs of malnutrition and weight loss.[ncbi.nlm.nih.gov]
  • The patient was suffering from an advance stage of celiac disease (CD), the delay in its diagnosis and in the establishment of a gluten-free dietled the patient to a severe proteincalorie malnutrition.[ncbi.nlm.nih.gov]
  • The clinical presentation of celiac disease has evolved from chronic diarrhea and malnutrition to mild nutrient insufficiencies.[ncbi.nlm.nih.gov]
  • Damage to the small intestine and the resulting nutrient absorption put people with celiac disease at risk for malnutrition and anemia.[asge.org]
Chronic Fatigue Syndrome
  • These outpatient tests are currently the best tools to distinguish between celiac and illnesses like chronic fatigue syndrome and irritable bowel syndrome that can cause similar symptoms.[celiacdisease.org]
  • Autoimmune and Other Conditions Associated with Celiac Disease Anemia 12-69% Autoimmune Hepatitis 2% Autoimmune Thyroid Disease 26% Chronic fatigue syndrome 2% Dermatitis Herpetiformis 25% Down's syndrome 12% Gluten ataxia 10-12% Idiopathic Dilated Cardiomyapathy[celiac.org]
  • fatigue syndrome 2% Dermatitis Herpetiformis 25% Down’s Syndrome 12% Gluten Ataxia 10-12% Idiopathic Dilated Cardiomyopathy 5.7% Juvenile Idiopathic Arthritis 1.5-6.6% Liver Disease 10% Lymphocytic Colitis 15-27% Microscopic Colitis 4% Peripheral Neuropathy[celiac.org]
  • The symptoms of celiac disease can be easily confused with those of other diseases such as irritable bowel syndrome, chronic fatigue syndrome, inflammatory bowel disease, or intestinal infections.[asge.org]
Diarrhea
  • The patient's diarrhea resolved after initiation of a gluten free diet. He gained 25 kilograms after discharge and did not require further hospitalizations for diarrhea.[ncbi.nlm.nih.gov]
  • We report an extremely rare case of CD103( ) γδ T LGL leukemia in a patient with celiac disease who presented with refractory diarrhea.[ncbi.nlm.nih.gov]
  • A 61-year-old obese woman developed severe diarrhea soon after bariatric surgery (BS), which was unresponsive to standard medical treatment.[ncbi.nlm.nih.gov]
  • We present a toddler with one month history of diarrhea and abdominal ultrasound showing ileo-ileal intussusception. Specific serological markers for celiac disease were positive.[ncbi.nlm.nih.gov]
  • Diarrhea is the most common symptom in untreated celiac sprue and is present in 45-85% of all patients. Diarrhea caused by celiac disease is due to the maldigestion and malabsorption of ingested nutrients.[symptoma.com]
Abdominal Pain
  • We report here a 6-year-old girl presenting with malaise, abdominal pain, loss of appetite, abdominal distension.[ncbi.nlm.nih.gov]
  • A fifteen-year-old girl was presented for chronic diarrhea and abdominal pain. Her physical examination had determined multiple hypopigmented patches.[ncbi.nlm.nih.gov]
  • One year after surgery, he had no abdominal pain or PCI recurrence. The above chronic symptoms were plausibly attributable to the PYY.[ncbi.nlm.nih.gov]
  • Symptoms included abdominal pain, diarrhea and weight loss. Laboratory tests showed reduced IgM, DQ2-HLA and negative anti-transglutaminase. Villous atrophy and diffuse immature lymphocytes were observed at histology.[ncbi.nlm.nih.gov]
  • The most common treatment-emergent adverse events in the Nexvax2 participants were headache (52%), diarrhoea (48%), nausea (37%), abdominal pain (26%), and abdominal discomfort (19%).[ncbi.nlm.nih.gov]
Constipation
  • This study aims to determine the prevalence of CD in patients with chronic constipation.[ncbi.nlm.nih.gov]
  • The suspicion of celiac disease was based on a combination of symptoms (poor growth, iron deficiency anemia, chronic abdominal pain, abdominal distension, constipation, "sad child"), IgA deficiency, in the presence of SLE diagnosis.[ncbi.nlm.nih.gov]
  • Patients treated with sucrosomial iron reported a lower severity of abdominal symptoms, such as abdominal and epigastric pain, abdominal bloating, and constipation, and a higher increase in general well-being ( 33% vs. 21%) compared to the iron sulfate[ncbi.nlm.nih.gov]
  • The main intestinal symptoms stated by the participants were abdominal bloating, excess flatulence, constipation, and gastroesophageal reflux. The most frequent extra-intestinal symptoms were fatigue, stress, and anxiety.[ncbi.nlm.nih.gov]
  • Women were more likely to present with constipation (OR 2.33; 95% CI 1.06-5.12; p 0.035). Anemia and abdominal distention or bloating were more frequently seen in women, but not on a statistically significant level.[ncbi.nlm.nih.gov]
Failure to Thrive
  • Celiac disease is a systemic immune mediated disease which usually presents with gastrointestinal symptoms, but it may present with extra gastrointestinal manifestations such as metabolic bone disease and failure to thrive.[ncbi.nlm.nih.gov]
  • This case highlights that the first manifestation of CD could be being overweight, and this finding seems to support the need to prescribe laboratory tests for CD not only to children with failure to thrive, as commonly recommended, but also to those[ncbi.nlm.nih.gov]
  • In infants and young children with untreated celiac disease, failure to thrive and growth retardation are relatively common.[symptoma.com]
  • In children, celiac disease can also lead to failure to thrive, delayed puberty, weight loss, irritability and dental enamel defects, anemia, arthritis, and epilepsy.[mayoclinic.org]
  • Growth problems and failure to thrive (in children). Seizures. Tingling sensation in the legs (caused by nerve damage and low calcium). Aphthous ulcers (sores in the mouth). Missed menstrual periods.[my.clevelandclinic.org]
Lactose Intolerance
  • However, some people continue to experience lactose intolerance despite successful management of celiac disease. Cancer.[mayoclinic.org]
  • intolerance Vitamin and mineral deficiencies Central and peripheral nervous system disorders Pancreatic insufficiency Intestinal lymphomas and other GI cancers (malignancies) Gall bladder malfunction Neurological manifestations, including ataxia, epileptic[celiac.org]
  • Undiagnosed or untreated celiac disease can lead to: Long-Term Health Conditions Iron deficiency anemia Early onset osteoporosis or osteopenia Infertility and miscarriage Lactose intolerance Vitamin and mineral deficiencies Central and peripheral nervous[celiac.org]
  • Other reasons could be confusing symptoms with another condition like lactose intolerance, fructose malabsorption , irritable bowel syndrome (IBS) or small intestinal bacterial overgrowth (SIBO).[dietvsdisease.org]
Aphthous Stomatitis
  • Recurrent aphthous stomatitis was reported in 26 patients (53.0%) and in 13 (25.5%) controls (p 0.005). Dental enamel disorders were reported in 7 patients (14.3%) and in 0 controls (p 0.002), with none having geographic tongue.[ncbi.nlm.nih.gov]
  • stomatitis Recurrent miscarriages or unexplained infertility Delayed puberty Osteopenia and osteoporosis Dental enamel defects Vitamin or mineral deficiencies (Common deficiencies include: iron, calcium, vitamin D, zinc, vitamin B12) Identify At-Risk[questdiagnostics.com]
Bone Pain
  • In patients with bone pain, non traumatic fractures and muscle weakness, osteomalacia should be kept in mind and proper diagnostic work-up should be performed to identify the underlying cause of osteomalacia such as celiac disease.[ncbi.nlm.nih.gov]
  • Symptoms of celiac disease vary and may include digestive problems, anemia, skin rash, and joint and bone pain. If you have celiac disease, you should not eat foods that contain gluten (including wheat, rye, barley, and oats).[my.clevelandclinic.org]
  • They may experience weight loss, gastric distension, features of other associated disorders such as diabetes, dermatitis herpetiformis (a particular type of skin disorder), and bone pain from osteoporosis/osteomalacia.[ddc.musc.edu]
  • Further symptoms vary and can include mouth ulcers, extreme fatigue, bone pain and others. A serious skin condition (called dermatitis herpetiformis) that results in an itchy rash with bumps and blisters is sometimes a result of this disease.[canada.ca]
  • Osteopenia and osteoporosis might cause bone pain for several reasons, including defective calcium transport by the diseased small intestine, vitamin D deficiency, and binding of luminal calcium and magnesium to unabsorbed dietary fatty acids.[symptoma.com]
Purpura
  • Consider serologic testing for celiac disease with any of following: Addisons disease, amenorrhea, apthous stomatitis, autoimmune myocarditis, chronic thrombocytopenic purpura, neuropsychiatric disease, epilepsy, low trauma fracture, lymphoma, metabolic[clinicaladvisor.com]
  • Celiac disease and keratoconjunctivitis: occurrence with thrombocytopenic purpura. Arch Intern Med 1982 ; 142 : 1037 . Stenhammar L and Ljunggren CG. Thrombocytopenic purpura and coeliac disease. Acta Paediatr Scand 1988 ; 77 : 764 –766.[bloodjournal.org]
Peripheral Neuropathy
  • […] differential diagnosis of peripheral neuropathy in children.[ncbi.nlm.nih.gov]
  • Celiac disease (CD) and non celiac gluten sensitivity (NCGS) can be responsible for neurological complications such as ataxia and peripheral neuropathies but also cognitive impairment.[ncbi.nlm.nih.gov]
  • The sensation is evidence of a nerve condition known as peripheral neuropathy. Credit: istockphoto Another vague complaint, headaches are common in people with celiac disease. In some cases, the disorder causes migraine headaches.[cbsnews.com]
  • They may suffer from abdominal distension and pain, and/or other symptoms such as: iron-deficiency anemia, chronic fatigue, chronic migraine, peripheral neuropathy (tingling, numbness or pain in hands or feet), unexplained chronic hypertransaminasemia[celiac.org]
Paresthesia
  • Carpal spasms and paresthesias of her extremities were present. Neuromuscular irritability was demonstrated by positive Chvostek and Trousseau signs.[ncbi.nlm.nih.gov]
  • Other symptoms of celiac disease may include: Headache Fatigue and weakness Joint pain Numbness and tingling (paresthesia) of the hands and feet Osteoporosis due to decreased absorption of calcium and vitamin D Skin rash Abdominal pain GERD and heartburn[medicinenet.com]
  • […] abdominal pain - 34-64% of patients Extraintestinal symptoms Extraintestinal symptoms may include the following: Anemia - 10-15% of patients Osteopenia and osteoporosis - 1-34% of patients Neurologic symptoms - 8-14% of patients; include motor weakness, paresthesias[emedicine.medscape.com]

Workup

The diagnosis is focused on testing for specific antibodies. For instance, if excessively high levels of endomysial and anti-tissue transglutaminase antibodies are found, the individual most definitely has celiac disease.

High levels of another antibody, anti-gliadin, may also be detected, but this doesn’t always mean a person has celiac disease [7]. However, anti-gliadin antibody levels are important when monitoring response to treatment, this is because they will usually begin to fall after a few months of successful treatment of celiac disease with a gluten-free diet.

People who test positive for celiac disease antibodies will be subjected to intestinal biopsy to confirm the diagnosis. A small intestinal biopsy is performed with an esophagogastroduodenoscopy (EGD). Loss of villi and other characteristics of celiac disease, such as an increased number of lymphocytes are present.

Hyponatremia
  • The patient had normal anion-gap metabolic acidosis (pH   7.16) with persisting hypokalemia, hyponatremia, hypomagnesemia and hypophosphatemia. In addition, severe vitamin deficiencies and coagulopathy were present.[ncbi.nlm.nih.gov]
Thrombocytosis
  • Extreme thrombocytosis as a sign of coeliac disease in the elderly: case report. Eur J Gastroenterol Hepatol 2002 ; 14 : 897 –900. Schafer AI. Thrombocytosis. N Engl J Med 2004 ; 350 : 1211 –1219. Pittschieler K.[bloodjournal.org]
Macrocytosis
  • Concomitant iron deficiency as can be seen in CD can result in atypical findings on the blood smear, and patients with deficiencies of folate and vitamin B 12 may not present with the characteristic macrocytosis.[bloodjournal.org]
HLA-DQ2
  • HLA-DQ2 was less frequent in UC patients (P 0.0287), and HLA-DQ8 in CD (P 0.0217). In women with UC, the frequency of DQ2.5cis (DQB1*02:01-DQA1*05:01) was reduced 50% [P 0.0344; preventive fraction (PF) 13%].[ncbi.nlm.nih.gov]
  • The disease is associated with human HLA-DQ genes encoding HLA-DQ2 and DQ8 proteins. In this study, 49 children patients of CD and 58 healthy control samples were genotyped for HLA-DQ genes using SSP-PCR technique.[ncbi.nlm.nih.gov]
  • Eight of them presented with the HLA-DQ2 haplotype, inherited from the grandfather, and 7/12 and 9/12 were positive for IgA anti-gliadin and IgA anti-transglutaminase antibodies, respectively.[ncbi.nlm.nih.gov]
  • Participants were assigned to cohort 1 if they were HLA-DQ2·5 homozygotes; other participants were assigned to cohort 2, or to cohort 3 subsequent to completion of cohort 2.[ncbi.nlm.nih.gov]
  • Celiac disease (CD) occurs in subjects positive for HLA-DQ2 and/or DQ8 gene loci at any age following ingestion of gluten-containing food.[ncbi.nlm.nih.gov]
HLA-DR3
  • A 1-to-3 nested case-control study, comprised of 207 celiac disease children and 621 controls matched for sex, birth year, and HLA genotype, was performed on a birth cohort of HLA-DR3-DQ2 and/or DR4-DQ8-positive children.[ncbi.nlm.nih.gov]
  • The selection of confounding variables was based on the criteria of having a P value P values Results Risk factors associated with development of CDA and CD were HLA-DR3-DQ2, Sweden as country of residence, female gender, and having a family history of[pediatrics.aappublications.org]

Treatment

The primary management of celiac disease is dietary. Complete elimination of gluten-containing grain products (including wheat, rye, and barley) is essential to treatment. However, complete avoidance of gluten-containing grain products is often difficult for patients to achieve and maintain. This is because certain products like wheat flour are virtually ever present in the American diet [8].

A small percentage of patients with celiac disease fail to respond to a gluten-free diet. In some patients who are refractory, corticosteroids can prove very helpful. In patients who fail to respond to corticosteroids, other comorbid conditions, such as lymphomas of the small intestine, have to be ruled out [9] [10].

Prognosis

With early removal of gluten from the diet, it becomes less likely for health complications to develop. The body quickly returns to health, in many cases, after the individual begins strict gluten-free nutrition.

To achieve optimal health, the gluten free diet must be maintained for life [5].

Etiology

Celiac disease is caused by a reaction to gliadin, a prolamin (gluten protein) found in wheat, and similar proteins found in the crops of the tribe Triticeae (which includes other common grains such as barley and rye).

Wheat subspecies (like spelt and durum) and related species (such as barley, rye, triticale and Kamut) also induce symptoms of celiac disease [2]. A small minority of people with celiac disease also react to oats. It is most probable that oats produce symptoms due to cross-contamination with other grains in the fields or in the distribution channels. Therefore, oats are generally not recommended. However, many companies assure the 'purity' of oats and are therefore still able to be consumed through these sources.

Other cereals like maize, millet, sorghum, teff, rice, and wild rice are safe for individuals with coeliac to ingest, as well as non-cereals like amaranth, quinoa, and buckwheat. Non-cereal carbohydrate-rich foods such as potatoes and bananas do not contain gluten and do not trigger symptoms of celiac disease.

Epidemiology

Celiac disease isn’t common. Its prevalence is decreased among blacks and those of Hispanic or Asian ethnicity. The incidence of symptomatic celiac disease in adults is estimated at 2 to 13 per 100,000 per year [3].

Sex distribution
Age distribution

Pathophysiology

Celiac disease has a strong hereditary connotation. The prevalence of the condition in first-degree relatives is 10% approximately.

A strong association exists between celiac disease and two human leukocyte antigen (HLA) haplotypes (DQ2 and DQ8). Damage to the intestinal mucosa is seen with the presentation of gluten-derived peptide gliadin, made up of 33 amino acids, by the HLA molecules to helper T cells. Helper T cells mediate the inflammatory response. Endogenous tissue transglutaminase deamidates gliadin into a negatively charged protein thereby increasing its immunogenicity. Absence of intestinal villi and lengthening of intestinal crypts characterize mucosal lesions in untreated celiac disease. More lymphocytes infiltrate the epithelium (intraepithelial lymphocytes). Destruction of the absorptive surface of the intestine leads to a maldigestive and malabsorption syndrome [4].

Prevention

The disease cannot be prevented.

Summary

Also known as celiac sprue and gluten sensitive enteropathy, celiac disease is mostly a chronic disorder of the digestive tract which brings about an inability to tolerate gliadin which is the alcohol soluble fraction of gluten. The protein gluten is mostly found in rye, barley and wheat [1].

In patients with ciliac sprue, ingestion of giladin triggers an immunologically mediated inflammatory response which ends up damaging the mucosa of the intestines. This brings about maldigestion and malabsorption of food nutrients.

Patient Information

Celiac disease is reaction to eating gluten. Gluten is a protein that is seen in wheat, rye and barley. 

In people that have celiac disease, consumption of this protein causes an immune response in your small intestine. Over a period of time the reaction damages the small intestine and this leads to malabsorption (inability to absorb other nutrients). 

With this intestinal damage, weight loss, bloating and diarrhea in some cases sets in. After a while, the brain, nervous system, liver, and other organs end up getting deprived of important nutrients. 

In children with this condition, malabsorption can affect development and growth. This intestinal irritation can lead to stomach pain especially after eating. 

There is no total cure for this disease but it can be controlled by following a strict gluten free diet. The diet can also lead to gradual healing of the intestine. 

References

Article

  1. Cristofori F, Fontana C, Magistà A, Capriati T, Indrio F, Castellaneta S, et al. Increased Prevalence of Celiac Disease Among Pediatric Patients With Irritable Bowel Syndrome: A 6-Year Prospective Cohort Study. JAMA Pediatr. Apr 21 2014.
  2. Squires JE, Fei L, Cohen MB. Role of Celiac Disease Screening for Children With Functional Gastrointestinal Disorders. JAMA Pediatr. Apr 21 2014.
  3. Ludvigsson JF, Zingone F, Tomson T, Ekbom A, Ciacci C. Increased risk of epilepsy in biopsy-verified celiac disease: A population-based cohort study. Neurology. May 1 2012;78(18):1401-7.
  4. Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA. ACG Clinical Guidelines: Diagnosis and Management of Celiac Disease. Am J Gastroenterol. May 2013;108(5):656-76.
  5. Green PH, Cellier C. Celiac disease. N Engl J Med. Oct 25 2007;357(17):1731-43.
  6. Ludvigsson JF, Leffler DA, Bai JC, et al. The Oslo definitions for coeliac disease and related terms. Gut 2013; 62:43.
  7. AGA Institute. AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease. Gastroenterology 2006; 131:1977.
  8. Bai JC, Fried M, Corazza GR, et al. World Gastroenterology Organisation global guidelines on celiac disease. J Clin Gastroenterol 2013; 47:121.
  9. Rubio-Tapia A, Hill ID, Kelly CP, et al. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol 2013; 108:656.
  10. Stenson WF, Newberry R, Lorenz R, et al. Increased prevalence of celiac disease and need for routine screening among patients with osteoporosis. Arch Intern Med 2005; 165:393.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-22 10:52