Detection of celiaca disease in its patients HAROLD T. PRUESSNER, M.D., University of the medical school of Roofing tiles in Houston

A patient pamphlet of the information in the celiaca disease, written by the author of this article, is provided in page 1039.

The celiaca disease is a genetic, immunological small intestine half-full enteropathy that causes the bad absorption. The immune inflammatory answer to the gluten causes damage frequently to many other fine weaves of the body. The condition is underdiagnosed frequently due to its presentations protean. The new data of the predominance indicate that the symptomatic and latent celiaca disease is present in one of 300 European slope people. The age of the beginning extends of childhood to the old age. The symptomatic presentations include bad general health, as well as dental, psychological and neurological dermatológicas diseases, hematologic, musculoskeletal, mucosal. The celiaca disease has predisposition genetic of 95 percents and, thus, autoinmunes is associated frequently to conditions such as type 1 of mellitus of the diabetes and disease of thyroid. The patients untreated have an increasing incidence of the osteoporosis and linfoma intestinal. The tests of excellent investigation of diagnosis are available now, including which they detected antigliadin and the antibodies antiendomysial. The therapy with a gluten-free diet is effective, giving by result the complete resolution of symptoms and secondary complications in almost all the patients. The local and national associations celiacas-sprue facilitate the care of patients with celiaca disease and support dietetic conformity.

The diseaseof eliac of C is to happen enteropathy of the gluten in children and adults. The condition is characterized by a sensitivity to the gluten that gives rise to the inflammation and atrophy of the mucosa of the small intestine. The clinical manifestations include the bad absorption with symptoms of the diarrea, the steatorrhea, and the nutritional deficiencies and the vitamin. The secondary immunological diseases, such as atópico dermatitis, herpetiformis of the dermatitis, alopecia and ulcers aphthous, can be the primary presentation.

Predominance

The magnitude of the predominance of the celiaca disease has been recognized only recently. The European society forpediátrica gastroenterology and the nutrition (ESPGAN) and the participation of the multicenter a great study, ¹ promoted by of 36 centers from 22 countries, has provided the important information in the incidence of the celiaca disease. The average incidence was found to be a case in each 1,000 alive births, with a range from the one in 250 to one in 4.000. When the age of the diagnosis was including in the density of the incidence of the celiaca disease, new born the predicted tariff was a case in each 300.² between blood donors, the predominance of the asintomática celiaca disease was found to be as high as one in 266.³

In the United States, people with the same genetic bottom hoped themselves that that the European population in that study had a similar incidence of the celiaca disease. In order to determine the predominance of the celiaca disease in the United States, they defended to 2,000 healthy donors of blood for the antibodies of antigliadin of IgA and IgG.⁴ those with the high levels were proven for the antibodies antiendomysial. The predominance of the elevated levels antiendomysial of the antibody in healthy donors of blood in the United States was found to be 1:250. This tariff is similar to the predominance in Europe, in where the subsequent small biopsies of the intestine have confirmed celiaca disease in all the patients who proved the positive for the antiendomysial antibody (positive prophetic value: 99 percents).^{the 5} authors of study ⁴of the United States conclude that the data suggest it celiaca disease can greatly be underdiagnosed and are relatively common in this country.

The incidence of the celiaca disease in the relatives of coeliac patients is perceivably greater than the incidence in the population of the control. A study⁶ found so much as four biopsy-proven cases of celiaca disease in a single family. The symptoms were often absent or so smooth in the relatives affected of proband that these relatives were not found out any abnormality. The predominance of the celiaca disease is approximately 10 percents in relatives of the first-degree.⁶

Patogenesia

PICTURE 1. Loss of villi, discharge celularidad of propria of laminates and extension marked of criptas with increasing activity mitotic. (3 175) PICTURE 2. Recovery of epitelio superficial acolumnado, with reappearance of a border of the brush. (X 192)

Normally, the ingested food does not remove to a local inmunorespuesta or systemic. The ingestion of the protein down-regulates the intestinal inmunorespuesta to that protein. This phenomenon is known like oral tolerance.⁷ in patients with celiaca disease, the immune system is activated abnormally by the gluten, specifically the portion of gliadin of the protein of the wheat, and you laminate (insoluble proteins) in rye, barley and oats.⁸ thus, the celiaca disease is genetic, immunological an intestine half-full, small enteropathy in what villi mucosal they are destroyed by cellular and humoral-half-full immunological reactions to the protein of gliadin.⁹ the loss of villi of operation limits the capacity of the small intestine to absorb foods, thus on the contrary affecting all the systems of the body (pictures 1 and2). The immunological answer to the gluten can also happen secondary in other corporal fine weaves, an example that is herpetiformis of the dermatitis.

The studies of patients with the celiaca disease that uses molecular techniques demonstrate a strong association with specific genotypes of HLA class II. Approximately 95 percents of patients with celiaca disease make a particular type of alpha of HLA DQ and chain beta codify by two genes, HLA-DQA1 0501 and HLA-DQB1 0201.¹⁰ if the genetic people ready to the celiaca disease do not ingest the gluten, she does not have any open disease. The ingestion delaying of products of the gluten with dietetic habits of breast-feeding or can change or delays the beginning of the disease.¹¹ virales exhibitions can drive an immunological answer in the susceptible people genetic to the celiaca disease; this happens with type 12 of adenovirus, that shares a sequence of eight to 12 amino acids with the toxic fraction of gliadin.¹²

Clinical Presentation

Childhood
During the first year of the life, an infant can show celiaca disease with vomiting intermittent, diarrea, the growth delays and lacks to prosper. The incidence of this early classic presentation in infants has diminished. Nevertheless, to prevent significant problems with the growth in infants, the confirmation of the celiaca disease is ¹³important ones (picture3).

PICTURE 3 enteropathy Gluten-sensible. The curve of the growth demonstrates initial normal growth from zero to 9 months, followed by beginning of the poor appetite with vomiting intermittent and of the diarrea after the initiation of the diet with gluten (single arrow). After biopsy- the diagnosis of the celiaca disease and the treatment with a gluten-free diet is confirmed (double arrow), growth improves. Rightsholder did not grant the rights to reproduce this electronic means article. For the article that lacks, it sees the original version of the impression of this publication.

Childhood
The children with celiaca disease can present/display with short stature, anemia, hepatitis, epilepsy and other conditions of the extragastrointestinal. With age, these presentations get to be subtler. In a study¹³ of a group of children of school defended for the antibodies of antigliadin of IgA, the positive titles were found in 19 of the children. The biopsies of Endoscopic were made in 18, and atrophy villous was found in 12. No of these children had demonstrated symptoms characteristic of the celiaca disease. Most frequent of his symptoms they were abdominal pain, estomatitis aphthous and atópico dermatitis (pictures 4 and5).

Angular Cheilitis (picture6) and recurrent ulcers aphthous (picture7) is frequent in adult children and with celiaca disease.¹³ these clinical results must urge the doctor to consider the diagnosis of the celiaca disease.

Young Adults
The initial presentation of the celiaca disease in patients in his 20s and 30s can be herpetiformis of the dermatitis. This condition appears generally like clearly or vesicles blood-dyed distributed symmetrically on the areas of the extensor of the elbows, the knees, the rumps, shoulders and the hairy leather (picture8). The intense prurito and/or the ardent sensations in the area happen the hours before the beginning of the vesicle. Herpetiformis of the dermatitis indicates by means of lights after the consumición of the foods that contain a high amount of gluten.

The small biopsies of the intestine of patients with herpetiformis of the dermatitis reveal the identical characteristics to those found in patients with celiaca disease.¹⁴ in a study¹⁵ of 212 patients with herpetiformis of the dermatitis that was handled during 25 years with a gluten-free diet, several advantages of the dietetic therapy were found, including (1) the necessity of the patients of the medication was reduced or suppressed, (2) to have solved enteropathy and (3) patients experienced a sensation of the well-being after beginning the diet.

In a study¹⁶ of the occurrence of malignancies and the survival of 305 patients with herpetiformis of the dermatitis as of 1970 to 1992, he was indicated that the incidence of linfoma of non-Hodgkin is increased perceivably of patients with herpetiformis of the dermatitis. The results also did not confirm any increase in mortality in patients with herpetiformis of the dermatitis that is dealt with a gluten-free diet.

The celiaca disease has not been recognized previously like cause of the alopecia. In an anticipated investigation,they proved ^{to 17} 254 patients committed consecutive with areata of the alopecia, not using antigliadin and the antibodies antiendomysial. The results were positive in three patients and, in spite of a deficiency of the symptoms of the gastrointestional, these patients experienced intestinal biopsy. The three were found to having celiaca disease, and the treatment with a gluten-free diet was initiated.

The certain problems of the skin, such as angular cheilitis, the recurrent ulcers aphthous or herpetiformis of the dermatitis must lead the doctor to consider celiaca disease like underlying cause.

When a boy 14-year-old with universalis of the alopecia was satisfied to the gluten-free diet, all its hair, eyebrows and eyelashes regenerated.¹⁸ in this advance study, the predominance of the associated celiaca disease to areata of the alopecia was found to be one in 85.

Adults
Bad absorption. The samples and the varied symptoms of the bad absorption can be caused by celiaca disease or many other diseases. The bad smooth absorption can be asintomática. With their gradual beginning, the classic manifestations of the flatulencia and the enlarged stools, grasientos and revolting-that smell not can recognize by the patient as samples of the celiaca disease. The bad absorption is due to suspect in any patient with loss and diarrea of the weight, and the samples and the symptoms of the specific vitamin or nutritional deficiencies. The last ones include visual disturbances, the neuropatía, the anemia, the diátesis osteopenic of the disease of the bone, tetany, hemorrágica or the infertility.

PICTURE 4. Atópico dermatitis in the arm. PICTURE 5. Atópico dermatitis in the posteriora part of a patient with celiaca disease. PICTURE 6. Angular Cheilitis in a patient with celiaca disease.

In celiaca disease, the clinical symptoms are determined by the severity and the next-to-proximal-to-distal degree of the intestinal injuries. The symptoms often declare in childhood and later they disappear, to only repeat itself in adult age. In some patients, the disease initially presents/displays in his 60s and^{beyond 19,20} (table1).

Anemia. The anemia is a frequent presentation of the celiaca disease. In a study,the antibodies defended ^{to 21} 200 consecutive patients who presented/displayed to a clinic of the hematology for antigliadin and antiendomysial. The patients with both positive titles experienced intestinal biopsy, and in 10 (5 percents), the results were positive for the celiaca disease. The predominance increased to 8,5 percents if they excluded the patients with anemia macrocytic and the patients with the drain that responded to the therapy of the iron. The authors of this study recommend including of the celiaca investigation in the algorithm of diagnosis of patients with anemia.

In a study carefully controlled,²² it was found that 25 percents of patients with partial celiaca disease and atrophy villous had hidden analyses of blood fecales positives, and 54 total percents of patients with atrophy villous had hidden analyses of blood fecales positives. The investigation for the hidden blood in stool mainly considers an investigation for the cancer, but the celiaca disease is due to consider in the differentiated diagnosis.

Osteopenia. Osteopenia can be initial to find in patients with celiaca disease. In a unique study,they found ^{to 23} eight asintomáticos relatives of the first-degree of patients with celiaca disease also to have celiaca disease. All were initially diagnosed by the serología, followed by the demonstration histologic of atrophy villous. Later, they found these patients to have reduced mineralización of the skeleton when they were evaluated by the dual x-ray of the energy absorptiometry. The study concluded that the reduced mineralización happens in asintomáticos coeliac patients, and who the early diagnosis and the treatment can prevent the desmineralización with the bone.

Graspings. There have been numerous information of children and adults with the graspings associated to celiaca disease. The studies have provided a certain penetration in this condition. The institute of pediatría clinical²⁴ evaluated to 783 patients referred due to graspings. The tests of the serología for antigliadin and the antibodies antiendomysial were made in all these patients. In one cohorte of 36 patients who also had clinical evident celiaca disease, was not observed any other graspings after the treatment with a gluten-free diet. In a second group of nine patients, the celiaca disease was not recognized due to smooth or absent symptoms, but the diagnosis was confirmed by jejunal biopsy. Three of these nine patients demonstrated calcifications occipital in the projection of image of the brain (picture9).

In another the cerebral study, ²⁵ 31 patients with epilepsy and calcifications (a disclosed complication of the celiaca disease) they experienced the investigation and the endoscopia of the blood. Of these patients, 24 were diagnosed with celiaca disease. The authors of this study found that a gluten-free diet only beneficial era in affecting the clinical course of the epilepsy if the diet began soon after the beginning of the graspings.

A boy with the insurmountable graspings, the calcifications occipital and the deficiency folate due to the celiaca disease experienced the therapeutic resección of the occipital lobe straight and continued being grasping-free by four years.pathological examinación ²⁶ of the fine weave of the brain revealed a cortical vascular abnormality with unequal pial angiomatosis, fibrosed the great veins and microcalcifications, indented. These abnormalitys were similar, although they are nonidentical, to those found in patients with the syndrome of Sturge-Weber.

A cerebralrevision ²⁷ of 39 articles published on patients with celiaca disease, calcifications and epilepsy concluded that the exact pathogenic process was stranger. Chronic the acid deficiency folic in patients untreated was considered a possible explanation. The mental weakening extremely variable era.

	Rightsholder did not grant the rights to reproduce this electronic means article. For the article that lacks, it sees the original version of the impression of this publication.
PICTURE 7. recurrentulcersaphthous (left and right) in patients with celiaca disease.

Hepática Disease. The celiaca disease has been recognized of length like cause of the chronic hepática pathology.²⁸ in a report,²⁹ three seriously presented/displayed ill patients with the clinical evidence and of the laboratory of the disease of higado but the any evidence of the viral hepatitis. Each patient had minimum or intermittent gastrointestinales symptoms; the biopsies of the liver demonstrated to nonspecific changes or the greasy infiltration. Due to the nature they protean of the presentations of the patients, the diagnosis were delayed six months until established by duodenal biopsy endoscopic.

PICTURE 8.Herpetiformis of the dermatitis. Vesiculation, the symmetrical crusts and erosions are distributed on the areas of the extensor of the elbows, knees, rumps, shoulders and hairy leather, with a tendency to group of individual injuries.

In another study,³⁰ serums were analyzed for the antibodies of gliadin (IgA and IgG) from 327 consecutive patients with disease of the chronic higado one. The antibodies of gliadin were detected in 19 patients; 10 of these patients had biopsies, and a diagnosis of the celiaca disease was confirmed in five. The authors suggest it celiaca disease is considered in cases of the disease of higado "cryptogenic" chronic.

Associate Diseases

Type 1 Of Mellitus Of the Diabetes
An advance study ³¹of cohorte to determine the predominance of the celiaca disease in 47 patients with mellitus of the diabetes of type 1 was undertaken in a medical center of the army. The test of the antibody of Antiendomysial was used for the investigation; the diagnosis required evidence histologic of atrophy villous and hiperplasia secret. Three of the 47 patients (6,4 percents) with diabetes also had celiaca disease. The authors conclude that the celiaca disease appears to be commonest in patients with diabetes of the type 1 that in the general population of the United States. In another report,diabetes ³² was present in 5.4 percents of coeliac patients, compared with only 1,5 percents of subjects of the control.

Disease De Tiroides
An evident association exists between the disease of thyroid and the celiaca disease. In a study,they defended ^{to 33} 83 patients with disorder autoinmune of the thyroid for the celiaca disease. They found to three patients with asintomática celiaca disease and a patient who had been diagnosed previously with celiaca disease, giving a total frequency of 4,8 percents. On the contrary, they found one of sex-matched donors of age 249 and of blood to have celiaca disease.

TABLE 1 Correlation of manifestations, the patofisiología and clinical results of the laboratory in the processes of Malabsorptive Samples and symptoms Patofisiológico mechanism Abnormalitys of the laboratory Gastrointestinal Diarrea Bad absorption of the fat, carbohydrate and the protein Weight of the stool > 200 g Weight of the stool diminished to normal with express Loss of the weight Bad absorption nutrient Fat increasing stool, diminished proteins of the serum The abdominal flatulencia, borborygmi, distention, revolting-smelling exonerate the belly The bacterial fermentation of malabsorbed the carbohydrates and the proteins Increasing production of the flato Enlarged, grasientos stools Bad fat absorption Fat increasing stool, low level of carotene of the serum Hematopoietic Anemia Deficiencies of the iron, pyridoxine, folate and vitaminB 12 Anemia of Microcytic, macrocytic or dimorfa Hemorrágica Diátesis Deficiency of vitamin K Prolonged time of the prothrombin Musculoskeletal Bony pain (disease osteopenic of the bone) Calcium, vitamin D and bad absorption of the protein Hypocalcemia, hypophosphatemia, increased the level of phosphatase alkaline of the serum Tetany Calcium, magnesium, bad absorption of vitamin D Hypocalcemia, hypophosphatemia, increased the level of phosphatase alkaline of the serum, hypomagnesemia Amenorrhea, infertility, impotence Bad absorption with the undernourishment of the protein-calorie Low levels of the protein of the serum; it can have abnormalitys in the secretion of gonadotropin Probable vitamin D and deficiencies of calcium Increasing alkaline Phosphatase, increasing hormone of the paratiroides of the serum Skin and mucous membranes Cheilosis, glositis, estomatitis Deficiencies of the iron, the riboflavina, niacin, folate and vitaminB 12 Low levels of the iron, folate and vitamin B12 of the serum Purple Deficiency of vitamin K Prolonged time of the prothrombin Follicular Hiperqueratosis Deficiency of vitamin A Low level of carotene of the serum Dermatitis or escamoso acrodermatitis Zinc and essential deficiencies of fatty acid Serum low or urinary level of zinc Dermatitis of Hyperpigmented Deficiency of niacin Edema and/or ascitis Bad absorption of the protein Hypoalbuminemia Nervous system Xeroftalmía and blindness at night Deficiency of vitamin A Diminished level of carotene of the serum Peripheral Neuropatía Deficiency of the tiaminaof vitamin B 12 Diminished level of vitamin B12 of the serum Adapted with the permission of Powell D. Approach to the patient with diarrea. In: I ACCEPT of Yamada T, Alpers, Owyang C, ET al., eds. Text book of gastroenterology. Vol. 1, Philadelphia: Lippincott, 1991.

A study epidemiologist³² watched at 335 patients diagnosed with celiaca disease between an or 80 and 1990. The diseases associated of these patients were compared with age and sex-matched patients of the control who had several gastrointestinales symptoms. The thyroid diseases autoinmunes were found to be increased, happening in 5.4 percents of the patients with celiaca disease.

PICTURE 9.Computed tomográfica exploration that demonstrates to the occipital calcification in a patient with celiaca disease and epilepsy.

Down Syndrome
The patients with down syndrome have an incidence of the celiaca disease at least of 7 percents.investigation ³⁴ for the celiaca disease in 115 children with down syndrome using antigliadin, antibodies antiendomysial and of antireticulin of the serum and an intestinal test of the permeability gave rise to a positive diagnosis in eight children. The authors down recommend defending of all the patients with the syndrome for the celiaca disease. Table 2 summarizes physical symptoms, results, and the diseases associated to celiaca disease.

TABLE 2 Physical symptoms, results and diseases associated to celiaca disease System of the body Presentation General Systemic Adults: lassitude, inanition, depression, fatigue, irritability, general undernourishment with or without loss of the weight Children: irritability, fretfulness, emotional retirement or excessive dependency, nausea, anorexy, undernourishment with the abdomen protruberant, losing of the muscle of rumps, next thighs and arms; with or without vomiting and diarrea Skin and mucous membranes Estomatitis de Aphthous (recurrent) Angular Cheilitis Atópico dermatitis (persistent or recurrent) Herpetiformis of the dermatitis (in 5 percents of patients with celiaca disease) Areata of the alopecia (specially universalis of the alopecia) Melanosis (bronzium of cloasma) Nodosum of eritema Skeletal system Osteoporosis/osteopenia (in 100 percents of patients with celiaca disease) Dental defects of the enamel Short stature Arthritis or arthralgia (central arthritis-sacroiliitis in 63 percents of patients with celiaca disease) Bony, specially night pain System hematologic (the deficiency of the iron is the cause commonest) 10 to 40 percents of children 90 percent and acid deficiency, anemia folic of adults; Deficiencyof B 12 (rare) Leucopenia, coagulopathy and thrombocytosis. Gastrointestinal system The diarrea in 60 percents of the patients (small intestinal type), early diarrea happens with infrequent, great, watery, revolting the stools; one more a last diarrea happens more frequently Constipation in 20 percents of patients, with obstipation and the pseudo-obstruction occasional Intolerancia of lactose in 50 percents of patients with gastrointestinales symptoms Anorexy, pain nausea, vomiting, abdominal and swelling Pancreatitis, hepatitis, linfoma Immune system Diseases autoinmunes associated: Type 1 of mellitus of the diabetes Disease of thyroid Syndrome of Sjögren Disorders of the colágeno Reumatoide arthritis Disease of the higado one Selective deficiency of IgA Reproductive system Delayed puberty Infertility Neurological system Graspings, with or without the occipital calcification Unexplained diseases neuropathic, including ataxia and peripheral neuropathies Dementia Other associate conditions Down syndrome Nephropathy de IgA Alveolitis de Fibrosing of the lung Hyposplenism, with atrophy of bazo Based partly on the information of Alessio Fasano, M.D., Ivor D. Hill. M.B., Ch.B., M.D., in the university of Maryland, and Jose To Murray, M.D., in the university of Iowa.

Diagnosis

The causes of delay in diagnosis
The recognition of celiaca disease in base of the several manifestations of the disorder is difficult. In a study²⁰ of 228 patients with celiaca disease of the adult-beginning, it was found that 42 were diagnosed in age 60 or more ahead. They excluded seven patients with herpetiformis of the dermatitis, leaving to 35 patients in the analysis. Fifteen of the 35 patients had been seen -- with unexplained symptoms and abnormal analyses of blood -- for an average of 28 years by their attending physicians or department of the patient noncommitted of the hospital before the diagnosis of the celiaca disease was done.

The endomysial antibody of IgA is one of several used reliable tests in the diagnosis of the celiaca disease.

A national examination³⁵ of 1,937 members of the Canadian celiaca association dealed with the application the lacked diagnosis previous the celiaca disease. Of 686 patients with biopsy-proven celiaca disease, 299 (43 percents) had been given following the incomplete or lacked diagnosis previously: anemia, 47; tension, 45; nervous condition, 41; null and voidable syndrome of the intestine, 34; gastric ulcer, 23; allergy of the food, 19; colitis, 13; menstrual problems, 13; edema, 9; biliary calculations, 9; diverticulitis, 6; herpetiformis of the dermatitis, 4 and another one, 36.

Tests De Investigacio'n Of the Blood
The routine analyses of blood can be suggestive of the celiaca disease (table3). The blood for the specific tests of investigation must be drawn before they place to the patient in a gluten-free diet. The present tests of investigation include the antibodies of antigliadin of IgA, of IgG and antiendomysial antibody of IgA. In a comparative study⁵ of 3,783 subjects, the combined presence of the antiendomysial antibody and the antibody of antigliadin was prophetic of atrophy mucosal intestinal in 99.1 percents of subjects. If both tests of the antibody were negative, the mucous one was normal in 99.1 percents of subjects. After a gluten-free diet was followed by the affected patients, the levels of the antibody of antigliadin of IgA got to be imperceptible. The authors of this study conclude that the antiendomysial investigation of the antibody is an excellent test for the diagnosis and the recordativa letter of the celiaca disease and for the identification of asintomáticos patients.

TABLE 3 Routine patterns Of the Investigation Of the Blood That Could Give Early Indication of the bad absorption being from celiaca disease Tests Patofisiología Level of phosphatase alkaline Due to the essential paper of calcium in contractilidad of the muscle, its concentration of the blood is regulated carefully. The diminished absorption of calcium makes the paratiroides activate osteoclasts to maintain levels normal of calcium. Secret Osteoclasts phosphatase alkaline. Anemia Microcytic-hypochromic (sideropenic): the deficiency of the answer to the therapy of the iron can indicate the bad absorption Normocytic-normochromic (deficiency of the iron and folate) Cholesterol and levels of low density of the cholesterol Low, or "too good," due to the deficiency of the absorption and the diminished production being from the weakening of the liver. (the HD cholesterol is also under, probably due to the weakening of the liver.) Level of amino-transferase of aspartate Minimum range Level of the protein-albumen of the plasma Border loss

In a study,³⁶ 102 patients examined for nonspecific the abdominal symptoms experienced small biopsy of the intestine (they excluded the patients with herpetiformis of the dermatitis.) In this group, they diagnosed to 49 patients in last instance with celiaca disease. In these patients, the antibodies anti-endomysial of IgA had a sensitivity and a specificity of 100 percents. The sensitivity of the antibodies of antigliadin of IgG was 73 percents, and the specificity was 74 percents. The sensitivity of antigliadin of IgA was 82 percents, and the specificity was 83 percents. The authors of this study conclude that the antiendomysial antibody of IgA is the best test of investigation for the celiaca disease, except in the case of patients with the deficiency of IgA.

The treatment for the celiaca disease is a final gluten-free diet, that leads to finish the resolution of symptoms in most of the patients.

Pathological and clinical conformation
In 1990, the group of operation of ESPGAN³⁷ reviewed the criteria for the diagnosis of the celiaca disease. The group reaffirmed diagnosis with the small biopsy of the intestine that demonstrated atrophy villous and by the complete resolution of clinical symptoms whereas in a gluten-free diet. The operation group asked the previous recommendation of the biopsy of the recordativa letter to confirm the recovery villous.

Treatment

The treatment for the celiaca disease is a final gluten-free diet. This includes the elimination of proteins of the storage (you laminate) of the wheat, the barley, the rye and oats.³⁸ also include the elimination of the medication gluten to over-the-counter carefully verifying the labels to know if there are ingredients such that hidrolizó the proteins of the plant and the vehicle, modified starch of the food, solids of the cereal, and fibers of the helmet of oats, the most obvious flour of wheat and glutens. The homemade food preparation requires a strong commission to exclude the glutens.

TABLE 4 Celiaca Disease: Resources and information for the doctors The celiaca list in the university of the St. Juan listserv@maelstrom.stjohns.edu message: OBTAIN RECEPTION CELIACA Mike Jones: it refiérase to the file in the celiaca disease for the doctors and the patients; material to help to inform to patients on celiaca disease and to put on a diet control. mjones@DIGITAL.NET CEL-PRO: group of discussion with 2,000 subscribers in 30 nations, for the professionals only, with clinical interest or of the investigation in celiaca disease. In order to assemble CEL-PRO, contact < mjones@DIGITAL.NET

The important problems appear when prepared foods purchase of the patients or eat in restaurants. The prepared soups, sauces and sauces contain great amounts of gluten frequently. The patients must be ordered to read all the labels in packed foods to help them to determine if the product contains the gluten. The doctors must animate to patients who assemble a coeliac group of aid (it see the patient pamphlet of the information). The patients with celiaca disease must be followed carefully to help to assure conformity dietetic and to diminish morbosidad of the osteoporosis, linfoma and other diseases associated to celiaca disease.

Final Commentary

The new data have determined that the celiaca disease is commonest than they were thought previously. The diverse secondary clinical manifestations do a diagnosis to him easy to lack. The doctors can be that they persecute without success expensive tests to explain the symptoms of a patient or the persistent abnormalitys of the laboratory. A high index of the mistrust is required to diagnose celiaca disease. A doctor must consider celiaca disease in a patient with a presentation of the confusion. The test of the diagnosis is progressive improvement in the symptoms of the patient when in an absolutely gluten-free diet. If it continues being the diagnosis in the question, a examinación endoscopic must be made and several specimens of the biopsy are due to take from the lowest duodeno and the superior jejunum. He is beneficial to cause that this fine weave is interpreted by a relative of the pathologist with celiaca disease. Table 4 enumerates the resources for the doctors interested in learning more on celiaca disease.

---

The Author

HAROLD T. PRUESSNER, M.D.,
now one retires. It was before professor and president of the department of the practice of the family and the medicine of community in the university of the medical school of Roofing tiles in Houston. The Dr Pruessner graduated as the university of the medical branch of Roofing tiles in Galveston, and had an exercise deprived in medicine of the family in the Christi compilation, Tex.

Treat the correspondence to Harold T. Pruessner, M.D., P.O. Box 646, Caldwell, TX 77836-0646. The reimpresiones are not available of the author.

The author thanks for Soul Morgan Pruessner, R.N., to review the manuscript; the coeliac states of America, Inc., Janet And Rinehart, president of Sprue Association/United, for the information on celiaca disease; Or Jose Jaros, M.A., M.S.L.S., director of the medical library of science in the center of the science of the health of the university of Roofing tiles A&M, for the resources and help of the investigation, and Barbara C. Thomas, M.S.L.S., for the additional aid with the manuscript.

Pictures 1 and 2 of Scully RE, mark EJ, McNeely WF, clinicopatológicos exercises of McNeely Or Weekly. English N J Med 1988;319(17):1139-48. Picture 3 of the disorders of Ulhen M. Malabsorptive. In: Nelson WE, ed. Text book of Nelson of pediatría. fifteenth ed. Philadelphia: Saunders, 1996:1091. 4 pictures and courtesy 5 of Fred F. Costrow II and George W. Hetherington, Jr, Houston, Tex Appear 6 of Allen cm, Shirt C. Diseases of the mouth and the lips. Angular Cheilitis. In: Sams WM, lynch PF, eds. Main and practical of the dermatology. 2.o ed. New York: Churchill Livingston, 1996;940. Picture 7 (left) courtesy of the American academy of dermatology, Schaumberg, Illinois, slide no. 05053. Picture 7 (straight) of the Violoncelo JP, ed. The oral injuries were associated to disorders of the gastrointestional. In: Sleisenger Mh, Fordtran JS, eds. Gastrointestinal disease: patofisiología diagnosis/management. Vol. 2, 5to ed. Philadelphia: Saunders, 1993. Fine picture 8 of JD. Diseases of Immunobullous. Herpetiformis of the dermatitis. In: Sams WM, lynch PJ, eds. Main and practical of the dermatology. 2.o ed. New York: Churchill Livingston, 1996;461. Picture 9 courtesy of Luigi Greco, Universita I gave Napoli, Naples, Italy.

REFERENCES

1. Greco L, Maki M, I gave Donato F, ET to. Epidemiología of the celiaca disease in Europe and the Mediterranean area. A summary report on the study of the multicenter by the European society of pediátricas gastroenterology and the nutrition. In: Auricchio S, Visakorpi JK, eds. Intolerances common 1 of the food: epidemiología of the celiaca disease. New York: Karger, 1992:14.
2. Greco L, I gave Donato F, Ansaldi N, ET to. Analysis of the tendencies of the incidents -- an example of cohorte Italian. In: Auricchio S, Visakorpi JK, eds. Intolerances common 1 of the food: epidemiología of the celiaca disease. New York: Karger, 1992:25.
3. Hed J, Lieden G, Ottosson and, Strom M, Walan To, Groth Or, ET to. Antibodies of against-anti-gliadin of jejunal IgA and injuries mucosal in the healthy donors of blood [ letter ]. Lancet 1986;2(8500):215.
4. NonT, Horvath K, identification of the hill, Fasano To, Hammed To, antibodies of Magazzu G. Endomysium in blood donors predicts a high predominance of the celiaca disease in the E.E.U.U.. digestive Week of the disease and 96.a annual meeting of the American association of Gastroenterological [ extracts ]. Gastroenterology 1996; 110(4 Suppl):A1-1591.
5. Antibodies of Cataldo F, Luck To, of Lazzari R, Balli F, Nassimbeni G, Sailor V. Antiendomysium and celiaca disease: questions solved and without solving. A study multicenters Italian. Paediatr Act 1995;84:1125-31.
6. Wc De MacDonald, Dobbins Wo, EC Of Rubin. Studies of the familial nature of sprue coeliac using the biopsy of the small intestine. English N J Med1965;272:448-56.
7. Mowat. The regulation of the inmunorespuesta to the dietetic antigens of the protein. Inmunología Today 1987; 8:93-4.
8. of Ritis G, Auricchio S, Jones HW, Lew EJ, Bernardin JE, DD of Kasarda. (studies Ines vitro of the culture of the organ) of the toxicity of peptides specific of Uno-a-gliadin in celiaca disease. Gastroenterology 1988;94:41-9.
9. Doniach I, limpiabotas M. jejunal Duodenal and biopsies II. Histología. Gastroenterology 1957;33:71-86.
10. Sollid LM, Markussen G, Ek J, Gjerde H, Vartdal F, Thorsby And Evidence for a primary association of the celiaca disease to heterodimer particular of alpha/beta HLA-DQ. J Exp Med 1989;169:345-50.
11. Maki M, Holm K. Incidence and predominance of the celiaca disease in Tampere. The celiaca disease is not disappearing. Act Paediatr Scand 1990;79:980-2.
12. Kagnoff Intermediate frequency, Austin RK, Hubert JJ, Bernardin JE, DD Of Kasarda. Possible paper of adenovirus human in patogenesia of the celiaca disease. J Exp Med 1984;160:1544-57.
13. Troncone R, Greco L, enteropathy Gluten-sensible of the S. of Auricchio. Pediatr Clin Am1996;43:355-73 Of the north.
14. Fine JD. Diseases of Immunobullous. In: Sams WM Jr, lynch PJ, eds. Principles and practice of the dermatology. 2.o ed. New York: Churchill Livingstone, 1996:461.
15. Garioch JJ, Lewis HM, Sargent Sa, Leonard JN, Fries L. experience of 25 years of a gluten-free diet in the treatment of herpetiformis of the dermatitis. Br J Dermatol 1994;131:541-5.
16. Collin P, Pukkala and, Reunala T. Malignancy and survival in herpetiformis of the dermatitis: a comparison with celiaca disease. Gut 1996;38:528-30.
17. Celiaca disease of Corazza GR., Andreani mililiter, Future N, Bernardi M, Tosti To, of Gasbarrini G. and areata of the alopecia: report of a new association. Gastroenterology 1995;109:1333-7.
18. Celiaca disease of Corazza GR., Andreani mililiter, Future N, Bernardi M, Tosti To, of Gasbarrini G. and areata of the alopecia: report of a new association. Gastroenterology 1995;109:1333-7.
19. Masón RE, RA Of Giannella. Bad absorption. In: Rakel RE, ed. Present therapy 1995 of conec: the methods of treatment approved last for the medical medical instructor. Philadelphia: Saunders, 1995:450-3.
20. Hankey GL, Holmes GK. Celiaca disease in the old ones. Gut 1994;35:65-7.
21. RA of Corazza GR., Valentini, TA of Andreani mililiter, D'Anchino M, them levy, Ginaldi L, ET to. The subclinical celiaca disease is a frequent cause of the anemia of the iron-deficiency. Scand J Gastroenterol 1995;30:153-6.
22. Fine KD. The predominance of coeliac the hidden gastrointestinal drain in sprue. English N J Med 1996;334: 1163-7.
23. Mazure R, Vazquez H, Gonzalez D, Mautalen C, Pedreira S, Boerr L, ET to. Mineral affection of the bone in asintomáticos patients of the adult with celiaca disease. J Gastroenterol 1994;89:2130-4.
24. Gobbi G, branch F, Greco L, Lambertini To, Tassinari CA, Luck To, ET to. Celiaca disease, cerebral epilepsy, and calcifications. The group of Italian operation in celiaca disease and epilepsy. Lancet 1992;340:439-43.
25. Fois To, Vascotto M, I gave Bartolo RM, celiaca disease and epilepsy of I gave Frame V. in pediátricos patients. System 1994;10:450-4 Of Childs Nerv.
26. Abnormalitys vasculares of good bye, Andermann F, Robotaille and, of Oliver M, Bohane T, Andermann And Cortical in the syndrome of the celiaca disease, epilepsy, calcifications occipital bilateral, and deficiency folate. Ana Neurol 1993;34:399-403.
27. Cuvellier JC, Vallee L, Nuyts JP. Celiaca disease, cerebral calcifications and syndrome of the epilepsy. Pediatr Arc 1996;3:1013-9.
28. Hagander B, NOT of Berg, Brandt L, Norden To, Sjolund K, injury of Stenstam M. Hepatic in celiaca disease of the adult. Lancet 1977;2(8032):270-2.
29. Mitchison HC, CO of registry, Bateson MC, abnormalitys of Cobden I. Hepatic in celiaca disease: three cases of delayed diagnosis. Postgrad Med J 1989; 65(770):920-2.
30. Lindgren S, Sjoberg K, celiaca disease of Eriksson S. Unsuspected in disease of higado ' cryptogenic ' chronic. Scand J Gastroenterol 1994;29:661-4.
31. Rensch MJ, Merenich JA, Lieberman M, Long BD, Davis Dr, Band De Gluten-sensible McNally. enteropathy in patients with mellitus insulin-employee of the diabetes. Internal Med 1996;124:564-7 Of Ana.
32. Celiaca disease of Collin P, Reunala T, Pukkala and, of Laippala P, Keyrilainen Or, of Pasternack A. -- disorders associate and survival. Gut 1994;35:1215-8.
33. Disorders of the thyroid of Collin P, salmi J, Hallstrom Or, of Reunala T, Pasternack To Autoimmune and celiaca disease. Eur J Endocrinol 1994;130:137-40.
34. George EK, Mearin mililiter, branch J, von Blomberg BM, Stapel Therefore, goes Elburg RM, ET to. Of high frequency of the celiaca disease in down syndrome. J Pediatr 1996;128:555-7.
35. Davidson AG, Campbell JA. Herpetiformis of the celiaca disease and the dermatitis. The national examination indicates delays in diagnosis. Doctor 1992;38:2604-8 Of Fam Of the Tin.
36. Vogelsang H, Genser D, Wyatt J, lochs H, Ferenci P, Granditsch G, ET to. Investigation for the celiaca disease: an advance study in the value of noninvading tests. J Gastroenterol 1995;90:394-8.
37. Report of the group of operation of the European society of pediátricas gastroenterology and the nutrition. Criteria reviewed for the diagnosis of the celiaca disease. Boy 1990;65:909-11 Of Dis Of The Arc.
38. Mearin Kilolitro, Mulder CJ. Celiaca disease (enteropathy gluten-sensible). In: W of Haubrich, Schaffner F, eds. Gastroenterology de Bockus. 5to ed. Philadelphia: Saunders, 1995:1041-2.

---

Copyright © 1998 of the American academy of attending physicians.
This content is had by the AAFP. A vision of the person in line can make a listing of the material and can only use that listing for his or its personal reference, noncommercial. This material cannot be unloaded, be copied, be printed, be stored, be transmitted or be reproduced of another way in any means, except now it is known or it invented more ahead, according to the authorized thing in writing by the AAFP.