July 07/13: New Guidelines in Celiac Disease Diagnosis and Management
Rubio-Tapia A, Hill ID, Kelly CP, Calerwood AH, Murray JA.
ACG Clinical Guidelines: Diagnosis and Management of Celiac Disease
Am J Gastroenterol. 2013; 108: 656 - 676
Background: There has been a substantial increase in the prevalence of celiac disease (CD) over the last 50 years and an increase in the rate of diagnosis in the last 10 years. Given the changes in practice and recommendations for diagnosis and management of CD, it is timely that the American College of Gastroenterology (ACG) presents this detailed guide.
Summary: Celiac disease presentation can range from no symptoms to a wide range of gastrointestinal and non-gastrointestinal symptoms. CD is usually detected by serologic testing and confirmed by duodenal mucosal biopsies. IgA tissue transglutaminase (tTG) antibody is the preferred single test for the detection of CD in individuals over the age of 2 years. For children under the age of 2 and where IgA deficiency is suspected, IgA tTG test should be combined with IgA and IgG tests for deamidated gliadin peptides (DGP).
Several conditions are associated with a higher risk of CD and these patients and family members of CD patients should be screened for the disease. There is a proven link between the presence of HLA-DQ2 and DQ8 and testing negative for both these HLA types makes CD diagnosis very unlikely. The treatment for CD is primarily a gluten-free diet (GFD) which requires significant patient education, motivation and follow-up. Non-responsive CD occurs frequently and requires review and follow-up to exclude alternative diagnoses and ensure there is no gluten contamination of the GFD. Patients should be evaluated for disorders associated with CD as well as complications (including possible malignancy) arising from it. New therapies are being studied at the clinical trial stage but are not yet approved for practice. However, given the incomplete response of many patients to a GFD as well as the difficulty of adherence to the GFD over a long term, development of effective therapies for symptom control and reversal of inflammation and organ damage are needed. While the presence of CD is increasing worldwide, many patients remain undiagnosed and improved strategies for the optimal detection of patients are highlighted.
Comment: The ACG have completed an extensive and very detailed guideline document for the diagnosis and management of celiac disease. It covers when, how and whom to test, management and monitoring of CD and confounding issues at each step and how these should be dealt with. This is summarized in 45 recommendations, all of which are qualitatively evaluated and backed by evidence rated from high to low. A lengthy bibliography backs up the formulation of the recommendations and covers nearly all aspects of the disease. This paper provides a plethora of information for clinicians and scientists working in the area and is well-deserving of wide dissemination.