Celiac Disease

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Abstract
As many as one in every 100 to 200 persons in the United States has celiac disease, a condition resulting from an inappropriate immune response to the dietary protein gluten. The manifestations of celiac disease range from no symptoms to overt malabsorption with involvement of multiple organ systems and an increased risk of some malignancies. When celiac disease is suspected, initial testing for serum immunoglobulin A (IgA) tissue transglutaminase (tTG) antibodies is useful because it offers adequate sensitivity and specificity at a reasonable cost. A positive IgA tTG result should prompt small bowel biopsy with at least four tissue samples to confirm the diagnosis. However, 3 percent of patients with celiac disease have IgA deficiency. Therefore, if the serum IgA tTG result is negative but clinical suspicion for the disease is high, a serum total IgA level may be considered. Screening of asymptomatic patients is not recommended. The basis of treatment for celiac disease is adherence to a gluten-free diet, which may eliminate symptoms within a few months. Patients should also be evaluated for osteoporosis, thyroid dysfunction, and deficiencies in folic acid, vitamin B12, fat-soluble vitamins, and iron, and treated appropriately. Serum IgA tTG levels typically decrease as patients maintain a gluten-free diet.

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Celiac Disease
R. JOHN PRESUTTI, DO; JOHN R. CANGEMI, MD; HARVEY D. CASSIDY, MD; and DAVID A. HILL, DO
Mayo Clinic, Jacksonville, Florida
C
eliac disease (or celiac sprue) is
an autoimmune disorder with
a prevalence of approximately
0.5 to 1 percent in the United
States.
1,2
It is associated with inflammation
of the mucosa of the small intestine, which
may result in villous atrophy. Celiac disease
produces a variety of gastrointestinal symp-
toms that can begin at almost any age. Treat-
ment consists of removal of gluten proteins
from the diet, which improves and often
eliminates the small intestine pathology.
Pathophysiology and Epidemiology
Gluten proteins occur throughout our food
supply and are relatively resistant to diges-
tive enzymes. Incomplete digestion in the
upper gastrointestinal tract results in pep-
tide derivatives that are highly immunogenic
to patients with celiac disease. In affected
patients, after absorption in the small intes-
tine these proteins interact with the antigen-
presenting cells in the lamina propria caus-
ing an inflammatory reaction that targets the
mucosa of the small intestine. Rye, wheat,
and barley, alone or as ingredients in many
processed foods, contain gluten and may
elicit this immune response.
Two factors are involved in the develop-
ment of celiac disease—consumption of
gluten proteins and genetic predisposition.
It is not completely understood how gluten
sensitivity begins or whether early exposure
to gluten proteins increases the risk of sen-
sitivity. However, almost all patients with
celiac disease express human leukocyte
antigen (HLA)-DQ2 or HLA-DQ8, which
facilitate the immune response against glu-
ten proteins.
2
Concordance rates of 70 to
75 percent among monozygotic twins and
5 to 22 percent among first-degree relatives
have been reported.
1,2,3
Patients with type 1
diabetes mellitus, Down syndrome, Turner’s
syndrome, or an associated autoimmune
disorder are at increased risk of celiac dis-
ease (Table 1
1-5
).
Clinical Diagnosis
Many patients with celiac disease have diar-
rhea, borborygmus, abdominal pain, and
As many as one in every 100 to 200 persons in the United States has celiac disease, a condition resulting from an
inappropriate immune response to the dietary protein gluten. The manifestations of celiac disease range from no
symptoms to overt malabsorption with involvement of multiple organ systems and an increased risk of some malig-
nancies. When celiac disease is suspected, initial testing for serum immunoglobulin A (IgA) tissue transglutamin-
ase (tTG) antibodies is useful because it offers adequate sensitivity
and specificity at a reasonable cost. A positive IgA tTG result should
prompt small bowel biopsy with at least four tissue samples to con-
firm the diagnosis. However, 3 percent of patients with celiac disease
have IgA deficiency. Therefore, if the serum IgA tTG result is nega-
tive but clinical suspicion for the disease is high, a serum total IgA
level may be considered. Screening of asymptomatic patients is not
recommended. The basis of treatment for celiac disease is adherence
to a gluten-free diet, which may eliminate symptoms within a few
months. Patients should also be evaluated for osteoporosis, thyroid
dysfunction, and deficiencies in folic acid, vitamin B
12
, fat-soluble
vitamins, and iron, and treated appropriately. Serum IgA tTG levels
typically decrease as patients maintain a gluten-free diet. (Am Fam
Physician 2007;76:1795-1802, 1809-10. Copyright © 2007 American
Academy of Family Physicians.)
This article exempli-
fies the AAFP 2007 Annual
Clinical Focus on manage-
ment of chronic illness.
T
Patient informa-
tion: A handout on celiac
disease, written by the
authors of this article, is
provided on page 1809.
Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright ©2007 American Academy of Family Physicians. For the private, noncommercial
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Celiac Disease
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December 15, 2007
weight loss (Table 2
6-11
). However, the disease can affect
several organ systems, including the skin, liver, nervous
system, bones, reproductive system, and endocrine sys-
tem.
12,13
Dermatitis herpetiformis (Figure 1), a pathog-
nomonic skin eruption, occurs in 10 to 20 percent of
patients with celiac disease.
14
Because the small intestine can compensate if the
degree of involvement is limited, many patients (up to
38 percent) are asymptomatic.
2,15
The disease is often
diagnosed only through careful attention to clini-
cal signs such as iron deficiency anemia or osteopo-
rosis, through screening of patients at increased risk,
or through other testing. One report found that up to
36 percent of patients with celiac disease had previ-
ously received a diagnosis of irritable bowel syndrome.
9
Common conditions that should be considered in the
differential diagnosis are listed in Table 3.
10
A suggested
diagnostic approach to patients with possible celiac dis-
ease is summarized in Figure 2.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Key clinical recommendation
Evidence
rating References
IgA tissue transglutaminase antibodies and IgA endomysial antibodies are appropriate first-line
serologic tests to rule in celiac disease.
C 5, 6, 16, 17, 20
Because IgA deficiency can cause false-negative results, total IgA levels should be measured
in patients at high risk for celiac disease who have negative results on serologic testing.
C 2, 5, 17
Small bowel biopsy should be performed to confirm the diagnosis of celiac disease in patients
with abnormal results on serologic testing.
C 2, 5, 6, 16
A gluten-free diet is recommended as the primary treatment for celiac disease. A 2, 23, 26
IgA = immunoglobulin A.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1760 or http://
www.aafp.org/afpsort.xml.
Table 2. Signs and Symptoms
of Celiac Disease
Sign or symptom
Prevalence in patients
with celiac disease (%)
Common
Diarrhea 45 to 85
Fatigue 78 to 80
Borborygmus 35 to 72
Abdominal pain 34 to 64
Weight loss 45
Abdominal distention 33
Flatulence 28
Uncommon or rare
Osteopenia or osteoporosis 1 to 34
Abnormal liver function 2 to 19
Vomiting 5 to 16
Iron-deficiency anemia 10 to 15
Neurologic dysfunction 8 to 14
Constipation 3 to 12
Nausea 4
Information from references 6 through 11.
Figure 1. Dermatitis herpetiformis.
Table 1. Risk Factors for Celiac Disease
Risk factor
Prevalence of celiac
disease among those
with risk factor (%)
Dermatitis herpetiformis 100
First-degree relative with
celiac disease
5 to 22
Autoimmune thyroid disease 1.5 to 14
Down syndrome 5 to 12
Turner’s syndrome 2 to 10
Type 1 diabetes mellitus
Children 3 to 8
Adults 2 to 5
Information from references 1 through 5.
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Diagnostic Tests
No single test has been universally accepted as the stan-
dard for diagnosing celiac disease. However, serologic
testing and small bowel biopsy are highly sensitive and
specific in making the diagnosis, particularly in patients
with symptoms suggestive of celiac disease and in those
at increased risk (e.g., those with a family history of the
disease, those with an associated autoimmune disorder).
16
Diagnostic testing must be performed while the patient
is on a diet that includes gluten-containing foods.
Patients with persistent gastrointestinal symptoms
such as diarrhea, malabsorption, weight loss, abdominal
pain, gas, and bloating should be evaluated for celiac
disease. Diagnostic testing should also be considered
in patients with premature osteopenia or osteoporosis,
unexplained iron deficiency anemia, or unexplained
Table 3. Differential Diagnosis of Celiac Disease
Anorexia nervosa
Autoimmune enteropathy
Bacterial overgrowth
Collagenous sprue
Crohn’s disease
Giardiasis
Human immunodeficiency
virus enteropathy
Hypogammaglobulinemia
Infective gastroenteritis
Intestinal lymphoma
Irritable bowel syndrome
Ischemic enteritis
Lactose intolerance
Other immunodeficiency
states
Soy protein intolerance
Tropical sprue
Tuberculosis
Whipple’s disease
Zollinger-Ellison syndrome
Information from reference 10.
Evaluation for Celiac Disease
Figure 2. Algorithm for an approach to patients with possible celiac disease. (IgA = immunoglobulin A; tTG = tissue
transglutaminase.)
Patient presents with symptoms of celiac
disease and is not on a gluten-free diet
Perform serologic IgA tTG antibody testing
Positive result Negative result
Small bowel biopsy High clinical suspicion
for celiac disease?
Positive result Negative result
Diagnosis confirmed;
begin gluten-free
diet and monitor
Follow up on patient;
consider other diagnoses;
consider repeat biopsy
NoYes
Small bowel biopsy Low probability of
celiac disease; consider
total IgA test to rule
out IgA deficiency
Positive result Negative result
Treat as celiac disease and
monitor for improvement
Diagnosis eliminated;
look for other causes
that mimic celiac disease
Improvement in symptoms?
Diagnosis confirmed Evaluate for possible secondary
cause of symptoms
Yes No
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December 15, 2007
liver abnormalities, and in high-risk patients with any
of these findings or unexplained gastrointestinal symp-
toms (Table 4
6
). Screening in asymptomatic patients is
not recommended.
SEROLOGY
The most common serologic markers used for celiac
disease screening are serum immunoglobulin A (IgA)
endomysial antibodies and IgA tissue transglutaminase
(tTG) antibodies.
17-19
Testing for gliadin antibodies is no
longer recommended because of the low sensitivity and
specificity for celiac disease. Most studies have found
the sensitivity and specificity of testing for IgA endo-
mysial and tTG antibodies to be greater than 95 per-
cent.
16,20
However, the sensitivity depends on the degree
of mucosal involvement. In addition, because tTG is the
autoantigen recognized by the endomysial antibody,
there is rarely a need to perform both tests.
16
The tTG
antibody test is less costly because it uses an enzyme-
linked immunosorbent assay; it is the recommended
single serologic test for celiac disease screening in the
primary care setting.
6,16,20
Most studies on celiac disease testing have involved
research populations with a high prevalence of the dis-
ease (up to 35 to 45 percent). When the prevalence is low,
as in the general U.S. population (approximately 0.5 to
1 percent
1,2
), the risk of a false-positive result is high even
with an accurate test (Table 5
1-5
). Therefore, confirma-
tory testing, including small bowel biopsy, is advised.
In some situations, testing for HLA phenotypes DQ2
or DQ8 may be useful.
14
HLA-DQ2 or HLA-DQ8, or
both, are found in approximately 40 percent of the gen-
eral population, but in more than 99 percent of patients
with celiac disease. If these genetic markers are absent,
celiac disease is unlikely.
2
Approximately 3 percent of patients with celiac disease
have IgA deficiency,
5
which may cause a false-negative
serologic test result. The American Gastroenterological
Association recommends measuring total IgA levels only
if IgA deficiency is suspected, or if serum tTG is negative
but celiac disease is still suspected.
2
Because serologic markers may have false-positive or
false-negative results, they cannot be relied on for the
diagnosis of celiac disease. However, positive serologic
Table 5. Implications of Screening for Celiac Disease in Different Populations
Population (approximate
prevalence of celiac disease)
Positive
predictive
value (%)
Negative
predictive
value (%)
True
positive
True
negative
False
positive
False
negative
General population (1%) 49.7 99.9 9,800 980,100 9,900 200
First-degree relatives (5%) 83.7 99.9 49,000 940,500 9,500 1,000
First-degree relatives, high
clinical suspicion (30%)
97.7 99.1 294,000 693,000 7,0 0 0 6,000
NOTE: Assumes 98 percent sensitivity and 99 percent specificity of tumor markers in 1 million patients.
Information from references 1 through 5.
Table 4. American Gastroenterological
Association Institute Recommendations
for Celiac Disease Screening
Consider testing in symptomatic patients at high
risk for celiac disease with any of the following
conditions:
Autoimmune hepatitis
Down syndrome
Premature onset of osteoporosis
Primary biliary cirrhosis
Unexplained elevations in liver transaminase levels
Unexplained iron deficiency anemia
Test selectively as part of the medical evaluation when
symptoms could be secondary to celiac disease:
Autoimmune thyroid disease
Cerebellar ataxia
First- or second-degree relative with
celiac disease
Irritable bowel syndrome
Peripheral neuropathy
Recurrent migraine
Selective immunoglobulin A deficiency
Short stature (in children)
Sjögren’s syndrome
Turner’s syndrome
Type 1 diabetes mellitus
Unexplained delayed puberty
Unexplained recurrent fetal loss
Information from reference 6.
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markers can indicate the need for further evaluation
with small bowel biopsy, particularly in patients at
increased risk. Conversely, negative serologic mark-
ers in low-risk patients without IgA deficiency have a
high negative predictive value, and small bowel biopsy
generally is not needed. Negative markers should never
prevent small bowel biopsy if the index of suspicion for
celiac disease is high.
SMALL BOWEL BIOPSY
Despite the advent of clinically accurate serologies, a
small bowel biopsy is required to confirm the diagnosis
of celiac disease for most patients.
16
Biopsy should also be
considered in patients with negative serologic test results
who are at high risk or in whom the physician strongly
suspects celiac disease.
However, the mucosal changes may vary from partial
to total villous atrophy, or may be characterized by subtle
crypt lengthening or increased epithelial lymphocytes.
Furthermore, these changes may be patchy, and muco-
sal abnormalities on intestinal biopsy (Figure 3) may be
missed. Variations in the severity of pathologic changes
on biopsy may obscure the typical changes found in
celiac disease, and patients with latent celiac disease may
have normal results on small bowel biopsy.
16
Therefore,
to avoid false-negative results on endoscopic biopsy,
most authorities recommend obtaining at least four tis-
sue samples, which increases the sensitivity of the test.
5
CAPSULE ENDOSCOPY
The biopsy is neither 100 percent sensitive nor specific
for celiac disease; other clinical entities, such as infection
Figure 3. Endoscopic and biopsy findings in patients with and without celiac disease. (A) High-definition endo-
scopic photo of normal small intestine. The villi are clearly visible with no evidence of atrophy or scalloping of the
folds. (B) Biopsy specimen of normal small intestine (hematoxylin-eosin; original magnification, 100). (C) Pill-
Cam image of small intestine in a patient with celiac disease, showing scalloping of the mucosal folds (arrows)
characteristic of a malabsorption pattern. There is also evidence of villous atrophy compared with normal.
(D) Biopsy specimen of small intestine in a patient with celiac disease (hematoxylin-eosin; original magnification,
100). Note the loss of villous architecture.
A B
C D
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December 15, 2007
(e.g., giardiasis, human immunodeficiency virus infec-
tion), enteritis, bacterial overgrowth, autoimmune enter-
opathy, or lymphoma, may have a similar appearance.
Capsule endoscopy in this setting may be helpful to distin-
guish lesions in the jejunum or ileum beyond the reach of
the standard endoscope if the diagnosis is in question.
21
Treatment
Treatment of celiac disease is based on avoidance of food
products that contain gluten proteins. It is essential that
the diagnosis of celiac disease be confirmed before sub-
mitting patients to this therapy. Key elements to success-
ful treatment include the motivation of the patient, the
attentiveness of the physician to comorbidities that need
to be addressed, and the assistance of a dietitian with
expertise in gluten-free diets.
THE GLUTEN-FREE DIET
Wheat, rye, and barley are the basic grain elements
that must be avoided. The role of oats is controversial.
Although they provide an excellent source of nutrients
and fiber, most commercial products are contaminated
with other grains, and only a purified source can be
used. The widespread use of glutens in food processing
requires patients to pay close attention to labels. Table 6
lists common foods that contain gluten and those that
are gluten free.
22
Adhering to a gluten-free diet can be extremely dif-
ficult and can have a significant negative impact on
perceived quality of life. It may produce considerable
psychological, emotional, and economic stresses.
23
However, appropriate diet is essential in the recovery
of patients with celiac disease, and formal consultation
with a trained dietitian is necessary. The dietitian plays a
vital role in helping the patient successfully adapt to the
necessary behavioral changes and may provide much of
the required follow-up. National celiac disease support
organizations (see the accompanying patient handout)
can provide patients invaluable resources for informa-
tion and support.
Table 6. Gluten Content of Some Common Foods
Category Contains gluten Usually gluten free
Breads, cereals,
rice, and pasta
Bread or pasta made from barley, bran, gluten
flour, graham flour, oat bran,* rye, wheat-based
semolina, spelt, wheat, or wheat germ
Cereals made with wheat, rye, barley, or oats,*
or with malt extract or malt flavorings
Bread, cereals, or pasta made from arrowroot
corn, buckwheat, corn, cornmeal, hominy,
millet, potato starch, rice, rice bran, sago, soy,
or tapioca
Puffed corn
Rice (brown or white); rice noodles
Vegetables and
beans
Creamed or breaded vegetables; some French fries
Canned baked beans
Plain, fresh, frozen, or canned vegetables
Soybeans
Fruits Some commercial fruit pie fillings and dried fruit All fruits
Dairy Malted milk; some milk drinks and flavored or
frozen yogurt
Milk and milk products that do not contain
gluten additives
Meat, poultry, fish,
shellfish, eggs,
and nuts
Any prepared with barley, oats, rye, wheat, or
gluten stabilizers or fillers, including some cold
cuts, frankfurters, sandwich spreads, sausages,
and canned meats
Plain meat, poultry, fish, and shellfish
Cold cuts, frankfurters, sandwich spreads, and
sausages that do not contain gluten fillers
Eggs; nuts and peanut butter
Snacks and
condiments
Many commercial salad dressings, prepared soups,
condiments, and sauces
Butter and margarine
Honey; jam and jelly; molasses; sugar
Coconut; hard candy; marshmallows; meringue;
plain chocolate
Beverages Flavored instant coffees; herbal teas
Hot cocoa mixes; nondairy cream substitutes
Pure instant or ground coffee; tea
Carbonated drinks; fruit juices
*—Pure oats are usually well tolerated but patients should be cautioned that oat products are frequently contaminated with gluten during processing.
NOTE: This is not a complete list. Patients should read food labels to confirm that food is gluten free. Patients should also check with their pharmacists
because some medications contain gluten.
Information from reference 22.
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COMORBIDITIES
The physician should ensure that nutritional deficiencies
associated with malabsorption are treated. Deficiencies
of iron, folic acid, vitamin B
12
, and fat-soluble vitamins
should be corrected, and levels should be monitored
to ensure that replacement is adequate. Thyroid func-
tion studies should be obtained at the time of diagnosis
because of the increased incidence of thyroid dysfunc-
tion in patients with celiac disease.
4
Osteoporosis is a common finding in patients with
celiac disease. The mechanism for bone loss is multifac-
torial and is thought to be related to secondary hyper-
parathyroidism from vitamin D deficiency and calcium
malabsorption.
1
With treatment of celiac disease, bone
density values often return to normal in children, but may
not do so in adults.
17
Consideration should be given to
testing bone mineral density in adults at the time of diag-
nosis, particularly in those who have been symptomatic.
4
COMPLICATIONS
Celiac disease is linked with increased mortality. This is
primarily because of the risk of malignancy; in particu-
lar, non-Hodgkins lymphoma, which is three to six times
more likely in patients with celiac disease.
2,24-26
Patients
with celiac disease are also at increased risk of oropha-
ryngeal, esophageal, and small intestinal adenocarci-
noma.
24,27
The specific cause of increased malignancy risk
is not known; however, several studies support the role of
a gluten-free diet in reducing the risk of cancer.
22,24,28,29
Follow-up
Long-term follow-up of patients with celiac disease is
recommended. Serologic markers may be used to moni-
tor compliance with a gluten-free diet. Antibody levels
typically return to normal within three to 12 months of
starting a gluten-free diet.
4
Lack of response may suggest
continued exposure to dietary gluten, which is often inad-
vertent, and patients should have further dietary instruc-
tion to ensure proper compliance with a gluten-free diet.
Most patients who make appropriate dietary changes
will improve. If the patient does not respond as expected
despite adherence to a gluten-free diet, the physician
should consider diseases that may mimic celiac disease,
such as microscopic colitis, pancreatic insufficiency,
inflammatory bowel disease, ulcerative jejunoileitis, col-
lagenous sprue, and T-cell lymphoma.
A repeat small bowel biopsy three to four months
after initiation of a gluten-free diet is not necessary if
the patient responds appropriately to therapy. Glu-
ten rechallenge with subsequent small bowel biopsy is
no longer recommended. If the diagnosis remains
uncertain, or if the response to therapy is not adequate,
further diagnostic testing for other diseases should be
performed (Table 3
10
). The natural history of untreated
asymptomatic disease has not been delineated.
Screening
In a population with a low prevalence of celiac disease,
such as that in the United States, the positive predictive
value of serologic markers may produce a significant
number of false-positive results that would necessitate
further evaluation with small bowel biopsy (Table 5
1-5
).
Screening an asymptomatic patient for celiac disease
must be weighed against the psychological, emotional,
and economic impact of a false positive result.
8,16,17
In
addition, the need to follow a strict diet indefinitely can
adversely affect the patient’s perceived quality of life.
Therefore, routine screening of the general population is
not recommended.
2
However, in persons at high risk for
celiac disease who exhibit any level of symptoms, appro-
priate testing is indicated.
The Authors
R. JOHN PRESUTTI, DO, is a consultant in the Department of Family Medi-
cine at Mayo Clinic in Jacksonville, Fla. He is also an assistant professor
of family medicine at Mayo Clinic College of Medicine in Rochester, Minn.
Dr. Presutti completed his residency training at Mayo Clinic, Jacksonville,
and his internship training at Sun Coast Hospital in Largo, Fla. He received
his degree in osteopathic medicine from Nova Southeastern University in
Fort Lauderdale, Fla.
JOHN R. CANGEMI, MD, is a consultant in the Division of Gastroenterol-
ogy and Internal Medicine at Mayo Clinic, Jacksonville, and an assistant
professor of medicine at Mayo Clinic College of Medicine. He completed
a fellowship in gastroenterology at Johns Hopkins University, Baltimore,
Md., and a residency in internal medicine at Mayo School of Graduate
Medical Education, Rochester. Dr. Cangemi received his medical degree
from Brown University in Providence, R.I.
HARVEY D. CASSIDY, MD, is chair of the Department of Family Medicine,
associate dean of medical and lab specialties, and an associate director
of the Department of Family Medicine Residency Program at Mayo Clinic,
Jacksonville. He is also an assistant professor of family medicine at Mayo
Clinic College of Medicine. He completed his residency at the Geisinger
Medical Center in Danville, Pa., and received his medical degree from
Jefferson Medical College in Philadelphia, Pa.
DAVID A. HILL, DO, is a resident in the Department of Family Medicine at
Mayo Clinic, Jacksonville.
Address correspondence to R. John Presutti, DO, Department of Fam-
ily Medicine, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224.
Reprints are not available from the authors.
Author disclosure: Nothing to disclose.
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  • [Show abstract] [Hide abstract] ABSTRACT: Celiac disease (CD) is an autoimmune enteropathy triggered in susceptible individuals by ingestion of gliadin-containing grains. Although the autoimmune process targets mainly the intestinal mucosa, CD can manifest itself with a variety signs and symptoms affecting any organ or tissue. For many years, CD has been underdiagnosed because of poor awareness. However, studies showing a high prevalence of CD in North America, followed by a consensus conference on CD organized by the National Institutes of Health, have fueled a campaign to raise awareness among subspecialists and primary physicians. Nevertheless, guidelines for the diagnosis of CD remain poorly appreciated and many health care professionals remain confused about its proper management. This review is intended to clarify "facts and fantasies" about CD diagnosis.
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