The large proportion of undiagnosed celiac patients may account for an accompanying underestimated cost to both the patient and the health care system because of repeated referrals to investigate unexplained disorders before an accurate diagnosis is made. In one recent analysis, mass screening for CD in a young adult population led to improved quality-of-life years by shortening the time to diagnosis and treatment; it was also found cost-effective.52 PCPs must be attentive to patients who may be at high risk for CD and implement combined serum tTG and EMA screening as the initial step in identification and treatment.4,10,11,20 Some form of standardized screening protocol may become inevitable.
CONCLUSION
The prevalence of CD has increased more than fourfold since 1950, and diagnosis is often significantly delayed. Increased awareness is needed among PCPs that CD in adults is likely to manifest with atypical (ie, nongastrointestinal) symptoms and signs. Judicious use of serologic screening for CD would lead to earlier diagnosis and more effective treatment, possibly preventing the potentially lethal refractory disease forms associated with chronic untreated CD.
REFERENCES
1. Ramos M, Orozovich P, Moser K, et al. Health 1. Catassi C, Fasano A. Celiac disease. Curr Opin Gastroenterol. 2008;24(6):687-691.
2. AGA Institute. AGA Institute medical position statement on the diagnosis and management of celiac disease. Gastroenterology. 2006;131(6):1977-1980.
3. Green PH, Jabri B. Coeliac disease. Lancet. 2003;362(9381):383-391.
4. Catassi C, Kryszak D, Louis-Jacques O, et al. Detection of celiac disease in primary care: a multicenter case-finding study in North America. Am J Gastroenterol. 2007;102(7);1454-1460.
5. Demirçeken FG, Kansu A, Kuloglu Z, et al. Human tissue transglutaminase antibody screening by immunochromatographic line immunoassay for early diagnosis of celiac disease in Turkish children. Turk J Gastroenterol. 2008;19(1):14-21.
6. van der Windt DA, Jellema P, Mulder CJ, et al. Diagnostic testing for celiac disease among patients with abdominal symptoms: a systematic review. JAMA. 2010;303(17):1738-1746.
7. Freeman HJ. Neurological disorders in adult celiac disease. Can J Gastroenterol. 2008; 22(11):909-911.
8. Tack GJ, Verbeek WHM, Schreurs MWJ, Mulder CJJ. The spectrum of celiac disease: epidemiology, clinical aspects and treatment. Nat Rev Gastroenterol Hepatol. 2010;7(4):204-213.
9. Farrell RJ, Kelly CP. Celiac sprue. N Engl J Med. 2002;346(3):180-188.
10. Green PHR, Cellier C. Celiac disease. N Engl J Med. 2007;357(17):1731-1743.
11. Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med. 2003;163(3):286-292.
12. Sud S, Marcon M, Assor E, et al. Celiac disease and pediatric type 1 diabetes: diagnostic and treatment dilemmas. Int J Pediatr Endocrinol. 2010;2010:161285. Epub 2010 Jun 23.
13. Swigonski NL, Kuhlenschmidt HL, Bull MJ, et al. Screening for celiac disease in asymptomatic children with Down syndrome: cost-effectiveness of preventing lymphoma. Pediatrics. 2006;118(2):594-602.
14. Bonamico M, Pasquino AM, Mariani P, et al; Italian Society of Pediatric Gastroenterology Hepatology (SIGEP); Italian Study Group for Turner Syndrome (ISGTS). Prevalence and clinical picture of celiac disease in Turner syndrome. J Clin Endocrinol Metab. 2002;87(12): 5495-5498.
15. Giannotti A, Tiberio G, Castro M, et al. Coeliac disease in Williams syndrome. J Med Genet. 2001;38(11):767–768.
16. Alaedini A, Green P. Narrative review: celiac disease: understanding a complex autoimmune disorder. Ann Intern Med. 2005;142(4): 289-298.
17. Fröhlich-Reiterer EE, Hofer S, Kaspers S, et al. Screening frequency for celiac disease and autoimmune thyroiditis in children and adolescents with type 1 diabetes mellitus: data from a German/Austrian multicentre survey. Pediatr Diabetes. 2008;9(6):546-553.
18. American Diabetes Association. Standards of medical care in diabetes—2009. Diabetes Care. 2009;32(1):S13–S61.
19. Losowsky MS. A history of coeliac disease. Dig Dis. 2008;26(2):112-120.
20. Evans KE, Hadjivassilou M, Sanders DS. Understanding ‘silent’ coeliac disease: complications in diagnosis and treatment. Gastrointest Nurs. 2010;8(2):26-32.
21. Lurie Y, Landau DA, Pfeffer J, Oren R. Celiac disease diagnosed in the elderly. J Clin Gastroenterol. 2008;42(1):59-61.
22. Vilppula A, Kaukinen K, Luostarinen L, et al. Increasing prevalence and high incidence of celiac disease in elderly people: a population-based study. BMC Gastroenterol. 2009 Jun 29;9:49.
23. Lo W, Sano K, Lebwohl B, et al. Changing presentation of adult celiac disease. Dig Dis Sci. 2003;48(2):395-398.
24. Alaedini A, Okamoto H, Briani C, et al. Immune cross-reactivity in celiac disease: anti-gliadin antibodies bind to neuronal synapsin I. J Immunol. 2007;178(10):6590-6595.
25. Tursi A, Giorgetti G, Brandimarte G, et al. Prevalence and clinical presentation of subclinical/silent celiac disease in adults: an analysis on a 12-year observation. Hepatogastroenterology. 2001;48(38):462-464.
26. Rostom A, Murray JA, Kagnoff MF. American Gastroenterological Association (AGA) Institute technical review on the diagnosis and management of celiac disease. Gastroenterology. 2006;131(6):1981-2002.
27. Ferguson A, Arranz E, O’Mahony S. Clinical and pathological spectrum of coeliac disease—active, silent, latent, potential. Gut. 1993;34(2): 150-151.