GASTROENTEROLOGY ARTICLE OF THE WEEK
March 14, 2002
Farrell RJ, Kelly CP. Celiac Sprue. N Engl J Med 2002;346:180-188,
1. Regarding the presenting features of celiac sprue
a. steatorrhea may be absent if the disease is limited to the more proximal parts
of the small bowel
b. presenting symptoms may mimic irritable bowel syndrome
c. may present as severe anemia during pregnancy
d. recurrent aphthous stomatitis maybe the only presenting symptom
e. Over 95% of adults will have clinically significant diarrhea on presentation
f. Iron deficiency alone is seldom the presenting sign of celiac sprue
2. Small bowel biopsy features found in patients with celiac sprue include
a. absent villi and hyperplastic crypts
b. increased number of intraepithelial lymphocytes
c. increased plasma cells and lymphocytes in the lamina propria
d. foamy macrophages
e. intramucosal hemorrhage
3. Regarding a gluten-free diet
a. products that contain wheat gluten, or produced from barley or rye must be
avoided
b. oats are probably safe, but often contaminated with wheat. Oats should be
avoided for the first 6-12 months until remission is achieved
c. Most foods contain wheat flour, so totally gluten-free diet is difficult
d. In the U.S. most gluten-free products carry a typical gluten-free symbol
e. lactose products can be used freely, particularly early in the treatment
f. symptomatic improvement is to be expected within 2 weeks after starting the
diet
True or False
4. Flattened, scalloped or otherwise abnormal duodenal folds are highly specific for celiac sprue.
5. In the evaluation of a patient with diarrhea and no other findings to suggest celiac sprue, a negative anti-gliadin and anti-endomysial antibody assays is sufficient to exclude the disease.
6. Celiac disease is rare among African-Americans, Chinese or Japanese patients.
7. Patients with suspected celiac sprue should be placed in a gluten-free diet empirically as a therapeutic trial.
8. First degree relatives of patients with celiac disease have a 10% prevalence of the disease.
9. Hyposplenism is not uncommon in adults with celiac sprue, these patients should receive the pneumococcal pneumonia immunization.
10. First time diagnosis of celiac sprue in people over age 60 is exceedingly rare
11. Anti-gliadin antibodies detect both IgA and IgG antibodies, but it is a less specific test than anti-endomysial antibody. Levels of IgA anti-gliadin antibodies can be used to monitor compliance with diet.
12. The endomysial antibody test detects IgA against tissue transglutaminase.
13. Dermatologic manifestations of celiac sprue
a. dermatitits herpetiformis, which is pruritic and occurs in extensor surfaces of
arms and legs, buttocks, trunk, neck and scalp.
b. the lesions should be biopsied to establish the diagnosis
c. Granular IgA deposits demonstrated by immunofluorescense is diagnostic
d. Skin biopsies should be done from the normal-looking skin
e. the skin lesions responds to treatment with dapsone and/or removal of gluten
from the diet
14. Refractory sprue
a. usually associated with an abnormal T-cell clone (cryptic intestinal T-cell
lymphoma)
b. can be complicated by ulcerative jejunoileitis, intestinal lymphoma and
collagenous sprue
c. should be suspected in patients with severe entiritis who do not respond to a 6
months of strict gluten free diet.
d. may respond to steroids, azathioprine and other immunosuppresants