Auteur Topic: ACG Clinical Guidelines: Diagnosis and Management of Celiac Disease (2013)  (gelezen 20130 keer)

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Nieuwe Amerikaanse richtlijn 2013.



2013 by the American College of Gastroenterology
ACG Clinical Guidelines:
Diagnosis and Management of Celiac Disease


Alberto Rubio-Tapia , MD 1 , Ivor D. Hill , MD 2 , Ciar α n P. Kelly , MD 3 , Audrey H. Calderwood , MD 4 and Joseph A. Murray , MD 1

This guideline presents recommendations for the diagnosis and management of patients with celiac disease.
Celiac disease is an immune-based reaction to dietary gluten (storage protein for wheat, barley, and rye) that primarily affects the small intestine in those with a genetic predisposition and resolves with exclusion of gluten from the diet.
There has been a substantial increase in the prevalence of celiac disease over the last 50 years and an increase in the rate of diagnosis in the last 10 years.

Celiac disease can present with many symptoms, including typical gastrointestinal symptoms (e.g., diarrhea, steatorrhea, weight loss, bloating, fl atulence, abdominal
pain) and also non-gastrointestinal abnormalities (e.g., abnormal liver function tests, iron defi ciency anemia, bone disease, skin disorders, and many other protean manifestations).
Indeed, many individuals with celiac disease may have no symptoms at all.

Celiac disease is usually detected by serologic testing of celiac-specific antibodies.
The diagnosis is confirmed by duodenal mucosal biopsies.
Both serology and biopsy should be performed on a glutencontaining diet.
The treatment for celiac disease is primarily a gluten-free diet (GFD), which requires signifi cant patient education, motivation, and follow-up.
Non-responsive celiac disease occurs frequently, particularly in those diagnosed in adulthood.
 
Persistent or recurring symptoms should lead to a review of the patient ’ s original diagnosis
to exclude alternative diagnoses, a review of the GFD to ensure there is no obvious gluten contamination, and serologic testing to confirm adherence with the GFD.

In addition, evaluation for disorders associated with celiac disease that could cause persistent symptoms, such as microscopic colitis, pancreatic exocrine dysfunction, and
complications of celiac disease, such as enteropathy-associated lymphoma or refractory celiac disease, should be entertained.

Newer therapeutic modalities are being studied in clinical trials, but are not yet approved for use in practice.
Given the incomplete response of many patients to a GFD-free diet as well as the diffi culty of adherence to the GFD over the long term, development of new effective therapies for symptom control and reversal of inflammation and organ damage are needed.

The prevalence of celiac disease is increasing worldwide and many patients with celiac disease remain undiagnosed, highlighting the need for improved strategies in the future for
the optimal detection of patients.


Am J Gastroenterol 2013; 108:656–676; doi: 10.1038/ajg.2013.79; published online 16 April 2013


Table 1 . Criteria for assigning grade of evidence
Type of evidence
Randomized trial=high
Observational study=low
Any other evidence=very low
Decrease grade if
• Serious ( − 1) or very serious ( − 2) limitation to study quality
• Important inconsistency ( − 1)
• Some ( − 1) or major ( − 2) uncertainty about directness
• Imprecise or sparse data ( − 1)
• High probability of reporting bias ( − 1)
Increase grade if
• Strong evidence of association — signifi cant relative risk of > 2 ( < 0.5)
based on consistent evidence from two or more observational
studies, with no plausible confounders ( + 1)
• Very strong evidence of association — signifi cant relative risk of
> 5 ( < 0.2) based on direct evidence with no major threats to
validity ( + 2)
• Evidence of a dose – response gradient ( + 1)
• All plausible confounders would have reduced the effect ( + 1)
Defi nition of grades of evidence
• High=Further research is unlikely to change our confi dence in the
estimate of effect
• Moderate=Further research is likely to have an important impact on
our confi dence in the estimate of effect and may change the estimate
• Low=Further research is very likely to have an important impact on
our confi dence in the estimate of effect and is likely to change the
estimate
• Very low=Any estimate of effect is very uncertain
Reprinted with permission from Camilleri et al. ( 264 ).


WHEN TO TEST FOR CD
Recommendations
(1) Patients with symptoms, signs, or laboratory evidence
suggestive of malabsorption, such as chronic diarrhea
with weight loss, steatorrhea, postprandial abdominal
pain, and bloating, should be tested for CD. (Strong
recommendation, high level of evidence)
(2) Patients with symptoms, signs, or laboratory evidence
for which CD is a treatable cause should be considered
for testing for CD. (Strong recommendation, moderate
level of evidence)
(3) Patients with a fi rst-degree family member who has a
confi rmed diagnosis of CD should be tested if they show
possible signs or symptoms or laboratory evidence of CD.
(Strong recommendation, high level of evidence)
(4) Consider testing of asymptomatic relatives with a fi rstdegree
family member who has a confi rmed diagnosis
of CD. (Conditional recommendation, high level of
evidence)

Table 2 . Conditions in which CD occurs more frequently than
in the general population and / or for whom a GFD may be
benefi cial

DIAGNOSIS OF CD
Recommendations
(1) Immunoglobulin A (IgA) anti-tissue transglutaminase
(TTG) antibody is the preferred single test for detection
of CD in individuals over the age of 2 years. (Strong
recommendation, high level of evidence)
(2) When there exists a high probability of CD wherein the
possibility of IgA defi ciency is considered, total IgA should
be measured. An alternative approach is to include both
IgA and IgG-based testing, such as IgG-deamidated gliadin
peptides (DGPs), in these high-probability patients.
(Strong recommendation, moderate level of evidence)
(3) In patients in whom low IgA or selective IgA defi ciency
is identifi ed, IgG-based testing (IgG DGPs and IgG TTG)
should be performed. (Strong recommendation, moderate
level of evidence)
(4) If the suspicion of CD is high, intestinal biopsy should
be pursued even if serologies are negative. (Strong
recommendation, moderate level of evidence)
(5) All diagnostic serologic testing should be done
with patients on a gluten-containing diet. (Strong
recommendation, high level of evidence)
(6) Antibodies directed against native gliadin are not
recommended for the primary detection of CD. (Strong
recommendation, high level of evidence)
(7) Combining several tests for CD in lieu of TTG IgA alone
may marginally increase the sensitivity for CD but reduces
specifi city and therefore are not recommended in low-risk
populations. (Conditional recommendation, moderate
level of evidence)
(8) When screening children younger than 2 years of age for
CD, the IgA TTG test should be combined with DGP
(IgA and IgG). (Strong recommendation, moderate level
of evidence)

Figure 1 . Celiac disease (CD) diagnostic testing algorithm. DGP, deamidated gliadin peptide; HLA, human leukocyte antigen; Ig, immunoglobulin; TTGA,
tissue transglutaminase antibody.

CONFIRMATORY TESTING IN CD
Recommendations
(1) Th e confi rmation of a diagnosis of CD should be based
on a combination of fi ndings from the medical history,
physical examination, serology, and upper endoscopy with
histological analysis of multiple biopsies of the duodenum.
(Strong recommendation, high level of evidence)
(2) Upper endoscopy with small-bowel biopsy is a critical
component of the diagnostic evaluation for persons with
suspected CD and is recommended to confi rm the diagnosis.
(Strong recommendation, high level of evidence)
(3) Multiple biopsies of the duodenum (one or two biopsies
of the bulb and at least four biopsies of the distal duodenum)
are recommended to confi rm the diagnosis of CD.
(Strong recommendation, high level of evidence)

Table 3 . Other causes of villous atrophy in duodenum
Tropical sprue
Small-bowel bacterial overgrowth
Autoimmune enteropathy
Hypogammaglobulinemic sprue
Drug-associated enteropathy (e.g., olmesartan)
Whipple disease
Collagenous sprue
Crohn’s disease
Eosinophilic enteritis
Intestinal lymphoma
Intestinal tuberculosis
Infectious enteritis (e.g., giardiasis)
Graft versus host disease
Malnutrition
Acquired immune defi ciency syndrome enteropathy

Table 4 . Summary of histologic classifi cations frequently used for celiac disease

ROLE OF ANCILLARY TESTING IN CD
Recommendations
(1) HLA-DQ2 / DQ8 testing should not be used routinely in
the initial diagnosis of CD. (Strong recommendation,
moderate level of evidence)
(2) HLA-DQ2 / DQ8 genotyping testing should be used to
eff ectively rule out the disease in selected clinical situations.
(Strong recommendation, moderate level of evidence)
Examples of such clinical situations include but are not limited to:
(3)
(a) Equivocal small-bowel histological fi nding (Marsh I-II)
in seronegative patients
(b) Evaluation of patients on a GFD in whom no testing
for CD was done before GFD
(c) Patients with discrepant celiac-specifi c serology and
histology
(d) Patients with suspicion of refractory CD where the
original diagnosis of celiac remains in question
(e) Patients with Down ’ s syndrome
(4) Capsule endoscopy should not be used for initial diagnosis
except for patients with positive-celiac specifi c serology
who are unwilling or unable to undergo upper endoscopy
with biopsy. (Strong recommendation, moderate level of
evidence)
(5) Capsule endoscopy should be considered for the evaluation
of small-bowel mucosa in patients with complicated
CD. (Strong recommendation, moderate level of evidence)
(6) Intestinal permeability tests, D-xylose, and small-bowel
follow-through are neither specifi c nor sensitive and are
not recommended for CD diagnosis. (Strong recommendation,
moderate level of evidence)
(7) Stool studies or salivary tests are neither validated nor
recommended for use in the diagnosis of CD. (Strong
recommendation, weak level of evidence)


ALLE OVERIGE FIGUREN ETC.
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