https://www.summitmedicalgroup.com/doctor/mleyva/ Learn about the difference between celiac disease, wheat allergy, non-celiac gluten sensitivity, and Irritable Bowel Syndrome (IBS). Our expert will discuss how each condition is diagnosed, symptom management, and treatment options available.

1. Should We All Be Gluten-Free?
Melissa Leyva, MD
Pediatric Gastroenterology
January 21, 2020
Montclair Public Library

2. Goals
• Understand what "gluten-free" means
• Understand the difference between :
Celiac disease
Non-celiac gluten sensitivity
Irritable bowel syndrome
Wheat allergy
• Is gluten-free living right for me?

3. What is Gluten?
• Gluten is a substance
found in various grains,
including wheat, barley,
and rye.
• Gluten gives bread and
pasta their elastic
properties.
Getty images

4. What Foods Contain Gluten?
• Bread, bagels, crackers
• Pasta, noodles
• Cereals
• Pastries, pies
• Cake, muffins, cookies, etc.

5. • Candy
• Communion wafers
• Cured pork products
• Gravy
• Imitation meat / seafood
• Sauces
• Self-basting turkeys
• Soy sauce
• Seasonings
• Some chips
What Foods Contain Gluten?

6. Non-Food Items
That Contain Gluten
• Medications
• Beer
• Lipstick

7. Reading Labels
The following ingredients contain gluten:
• Brewer's yeast
• Malt
• Modified food starch

8. "Gluten-Free" Food Labels
• Contains less than 20 ppm (parts per million) of gluten
• 10 mg/per day of gluten (1/8 teaspoon
flour) consumption is a safe level for the vast majority
of individuals with celiac disease.
• 10 mg gluten = 18 slices of gluten-free bread
with each slice containing 20 ppm of gluten.
• “Wheat-free" does not mean "gluten-free"

9. Foods That Don’t Contain Gluten
• Rice
• Corn
• Potato
• Tapioca
• Quinoa
• Buckwheat
• Fruits and vegetables
• Animal proteins (chicken, beef, pork, eggs, milk)
• Fish
• Maltodextrin is OK

10. Cost of Gluten-Free Diet
$6.19 (4 bagels)
$1.54 each
97%
MORE

11. Gastro-Intestinal Conditions
Associated with Gluten
• Celiac disease (CD)
• Non-celiac gluten sensitivity (NCGS)
• Irritable bowel syndrome (IBS)
• Wheat allergy

12. Celiac Disease
• Autoimmune disease
• Exposure to gluten causes damage to
the lining of the small intestine.

13. Pathogenesis of Celiac Disease
Celiac disease
Genetics Gluten
Gender
Infant feeding?
Infections
Others

14. Symptoms
• Abdominal pain
• Vomiting
• Abdominal distension
• Bloating/gassiness
• Diarrhea
• Constipation
• Weight loss

15. Symptoms
Non-GI Symptoms of Celiac Disease
• Skin rashes
• Depression
• Growth issues
• Headaches
• Osteoporosis
• Bone fractures
• Brain fog/learning issues
• Anemia
• Liver enzyme elevation/hepatitis
• Seizures/epilepsy
• Arthritis

16. Dermatitis Herpetiformis
• Red/pink flat lesions > itchy bumps > tense fluid filled
bumps (vesicles)
• Very itchy
• Symmetric distribution
• 90% no GI symptoms
Garioch JJ, et al. Br J Dermatol. 1994;131:822-6.
Fry L. Baillieres Clin Gastroenterol. 1995;9:371-93.
Reunala T, et al. Br J Dermatol. 1997;136-315-8.

17. Dental Enamel Defects

18. Some people with celiac disease have NO
symptoms
• First degree relatives of people with CD
• Patients with other autoimmune
diseases who are routinely screened for
CD
Symptoms

19. Who Gets Celiac Disease?
• Healthy population: 1:133 (0.5- 1%)
• Females more than males
• 1st degree relatives: 1:13 (7.5%)
• 2nd degree relatives: 1:42 (2.3%)
• More common in Europe and U.S.

20. High Risk Populations
• Certain genetic disorders or syndromes
• Down syndrome
• Turner syndrome
• Williams syndrome
• Other autoimmune conditions - Type 1 diabetes,
thyroid disease
• First degree relatives

21. Genetics
• 95 % of celiac patients are HLA DQ2 positive
• 2-3% of celiac patients HLA DQ8 positive
• 10% of patients have an affected first degree relative
• Negativity for DQ2/DQ8 excludes diagnosis of Celiac
Disease with 99% confidence

22. Symptomatic
Celiac Disease
Silent Celiac
Disease
Latent Celiac Disease
Genetic susceptibility: - DQ2, DQ8
Positive serology
Inflammation of
small intestine
Normal
Intestinal tissue

23. Risk of Other
Autoimmune Disorders
Prevalence of autoimmune disorders in celiac disease
related to duration of gluten exposure
Diagnosed before 2 years of age: 5%
Age 2-10 years: 17%
Greater than age 10 years: 24%

24. Diagnosing Celiac Disease
Blood tests (for screening purposes)
• Total IgA level
• Anti tissue transglutaminase antibodies (TTG) - HIGH
• TTG-IgA - most reliable test
• TTG-IgG - useful in patients who are IgA deficient
• Anti-endomysial antibodies (EMA) - POSITIVE
• Anti-gliadin antibodies (AGA) - HIGH
• HLA typing

25. mayoclinic.org
Diagnosing Celiac Disease

26. Endoscopic Findings
NodularityScallopingNormal Appearing

27. Diagnosing Celiac Disease
www.beyondceliac.org

28. Treatment
Strict, Gluten-free Diet
(GFD). Lifelong avoidance
of:
Wheat
Rye
Barley
(oats)

29. Gluten-Containing Grains to Avoid
Wheat Bulgar Filler
Wheat Bran Couscous Graham flour
Wheat Starch Durum Kamut
Wheat Germ Einkorn Matzo
Flour/Meal Barley Emmer
Semolina Barley Malt/ Extract Farro
Spelt Rye Triticale

30. Complications of
Celiac Disease
• Lymphoma/cancer (small intestine)
• Fertility issues (miscarriages, difficulty
conceiving)
• Osteoporosis/bone fractures
• Anemia
• Other autoimmune diseases

31. Nutritional Complications of
Untreated Celiac Disease
Low Iron
Low Folate
Low Vitamin B-12
Low Vitamins ADEK
Low Thiamine
Low Niacin
Low B6 (rare)
Low Beta-carotene
Low Zinc
Essential Fatty Acid
Deficiency

32. Non-Celiac Gluten Sensitivity (NCGS)
• Symptoms are similar to that of Celiac
Disease
• Abdominal pain, bloating, diarrhea, brain
fog

33. Non-Celiac Gluten Sensitivity
(NCGS)
Diagnosis
• Diagnosis of exclusion - no way to test for it
• Celiac blood work is normal
• Endoscopy is normal (usually)
• Improvement in symptoms with gluten restriction

34. Non-Celiac Gluten Sensitivity
(NCGS)
Treatment
• Gluten restriction - small amounts of gluten
are usually tolerated
•Reintroduction of gluten triggers symptoms

35. Irritable Bowel Syndrome (IBS)
Symptoms
• Abdominal pain
• Bloating
• Gassiness
• Diarrhea (IBS-D)
• Constipation (IBS-C)
• Diarrhea and Constipation (IBS-M)

36. Irritable Bowel Syndrome (IBS)
Diagnosis
• Diagnosis of exclusion
• No tests available to diagnose

37. IBS
• Who does it affect?
• Females more than males
• Pre-teens, teens, adults
• Affects 14% of population

38. Treatment
• FODMAP diet – effective in up to 75% of patients
Gastroenterol Hepatol (NY). 2019 Jan; 15(1): 16–26.)
• Gluten-free diet
• Lactose free diet
• Lifestyle (stress reduction, exercise)
• Medications
• Antispasmodics (hyoscyamine, dicyclomine)
• Depression/anxiety medication (SSRI’s)
IBS

39. IBS
www.monashfodmap.com

40. IBS
Conditions that can mimic IBS
• Celiac disease
• Small intestinal bacterial overgrowth (SIBO)
• Parasitic/bacterial infections
• Lactose intolerance
• IBD (Crohn’s disease, Ulcerative colitis)

41. Wheat Allergy
• IgE mediated hypersensitivity
• Reaction is often immediate

42. Wheat Allergy
Symptoms
• Rash/hives
• Shortness of breath/hoarseness
• Abdominal pain, vomiting, diarrhea
• Anaphylaxis

43. Wheat Allergy
Diagnosis
• Skin prick testing
• Blood work (RAST testing)

44. Wheat Allergy
Treatment
• Restriction of wheat
• Other grains (rye,
barley, oats) likely
fine
Chef Card

45. Comparison of Gluten Related
Conditions
Celiac Disease Non-celiac gluten
sensitivity
Irritable bowel
syndrome
Wheat allergy
Symptoms • abdominal pain
• diarrhea
• constipation
• gas
• neurological
• abdominal pain
• diarrhea
• constipation
• gas
• neurological
• abdominal pain
• diarrhea
• constipation
• gas
• rash/hives
• shortness of
breath
• abdominal pain
• vomiting
• diarrhea
• anaphylaxis
Onset of
symptoms
Hours to months Hours to days Hours to days Minutes to hours
Diagnosis • blood test
• endoscopy
• based on
symptoms
• based on
symptoms
• skin testing
• blood test
(RAST)
Damage to
Intestine
Yes No ? No No
Treatment strict GFD GFD Various wheat restriction,
other grains often
fine

46. Educational Resources
• celiac.org
• www.foodallergy.org (FARE - food
allergy research education)
• www.monashfodmap.com
• Gluten Freedom by Alessio Fasano, MD