World Digestive Health Day WDHD – May 29, 2016 MANAGING ADULT CELIAC DISEASE IN THE OUTPATIENT CLINIC, continued (PRE)-MALIGNANT CELIAC CONDITIONS There is an increased risk for malignancies, already recognized over 50 years ago.30 Small-bowel cancer, cancer of the esophagus, female celiac patients in their twenties and thirties with B-cell Non-Hodgkin lymphoma, and seniors in their sixties for Enteropathy Associated T-cell Lymphomas (EATL) are well recognized in current literature.1 Celiac disease is a common diagnosis, but malignant outcomes are rare. EATL is such an infrequent complication that the majority of gastroenterologists may never see it amongst the population of celiac patients they diagnose and see for follow-up.31,32 Evidence suggests the risk for increased mortality and malignancies is reduced in those who adhere to the diet. However, EATLs present themselves especially in those patients diagnosed above 50 years of age.30 Only 10% of patients referred to us with suspicion for (Pr)-EATL are diagnosed with those complications.32 The risks of malignancy related to CD reported in literature are likely to remain overestimated owing to either bias or confounding.32,33 REFRACTORY CELIAC DISEASE In the situation of non-responsiveness to a GFD, dietary adherence should be meticulously evaluated. Monitoring levels of tTgA and/or EMA are suitable for this purpose. Additionally, all patients should be referred to a skilled dietician. When inadvertent gluten ingestion is reasonably excluded, the CD diagnosis should be re-evaluated. Absence of the CD-related genotypes (HLA-DQ2.5 or HLA DQ8) at diagnosis is highly suggestive of misdiagnosis. When other causes or VA have been excluded, these patients are referred to as refractory CD (RCD). Since 2001, we have divided RCD into two types based on the absence (Type I) or presence (type II) of an, usually clonal, intraepithelial lymphocyte population with aberrant phenotype. 34 Our diagnostic approach and the latest insights in treatment options are readily available in literature.4 ESOPHAGEAL CANCER Around 90% of all esophageal cancers are related to lifestyle, such as tobacco, alcohol, diet, and overweight. Esophageal cancer is more than 10 times higher in patients with Barret’s esophagus. However, esophageal cancer is also higher in people with CD.35 In case of Barret’s esophagus, we screen our celiac patients in follow-up. Otherwise, we do not screen them for this minor risk factor. COLON CANCER Unfortunately, CD has strongly been suggested in the past to be related with some site specific intestinal malignancies. In contrast to this, according to the available reports the risk of colorectal cancer (CRC) has been described a similar or lower to that of the general population.36 Untreated CD may be protective, probably owing to impaired absorption of fat, hydrocarbons, and putative co-carcinogens implicated in the pathogenesis of CRC, which may be poorly absorbed and rapidly excreted.37 The reflex of gastroenterologists when patients present with diarrhea at their out-clinics is to recommend a colonoscopy with a very low threshold, so the majority of the elder celiac patient population already had a colonoscopy at diagnosis or follow-up. RISK OF CARDIOVASCULAR DISEASE Cardiovascular diseases that have been suggested to be associated with CD include ischemic heart disease (IHD), cerebrovascular events, and cardiomyopathy. The risk of IHD may be related to the pro-inflammatory activated immune cells like in Rheumatoid arthritis38 and with low folic acid state, could affect the development of arteriosclerotic lesions. In 2004, West et al. studied almost 4,000 patients with CD with respect to hypertension, hypercholesterolemia, heart disease, and stroke.39 However, they showed a lower prevalence of hypertension and hypercholesterolaemia in CD in comparison with controls. GFD gives a significant increase in BMI and cholesterol in celiac patients adherent to the diet.40 There is a body of reports published on cardiovascular risks in celiac patients, however, conclusions of some studies are at odds with each other. The co-occurrence of T1DM in some celiac patients should be taken into consideration.41 When we find arteriosclerosis during abdominal CT in the work-up of complicated CD referred for second opinion we start aspirin 100mg daily and keep the cholesterol below 4 mmol/L. Recent studies, however, did not recognize an increased risk of IHD in celiac patients.39 CONCLUSION A life-long GFD improves health and the quality of life in a vast majority of patients with CD, even in those with minimal symptoms.1 GFD is in daily practice (especially in the second and third world) difficult to sustain, owing to several barriers including social, cultural, economical, and practical aspects. Adher- World Digestive Health Day WDHD May 29, 2016 WGO Handbook on DIET AND THE GUT 37
WGO Handbook on Diet and the Gut_2016_Final
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