Dept. Medicine 1, Gastroenterology, Interventional Endoscopy, Functional Tissue Diagnostics, University Erlangen - Nürnberg Direktor: Prof. Dr. med. M. F. Neurath www.medizin1.klinikum.uni-erlangen.de Allergy School on Allergy Diagnosis in & beyond the Skin 2013 Erlangen, Germany, 25 – 28 July 2013
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Dept. Medicine 1, Gastroenterology, Interventional Endoscopy, Functional
Tissue Diagnostics, University Erlangen - Nürnberg
Direktor: Prof. Dr. med. M. F. Neurath
www.medizin1.klinikum.uni-erlangen.de
Allergy School on
Allergy Diagnosis in & beyond the Skin 2013 Erlangen, Germany, 25 – 28 July 2013
*wheat allergens, e.g. ω-5 gliadin, water- & salt-insoluble gliadin Pietzak M. Celiac disease, wheat allergy and gluten sensitivity: When gluten free is not a fad. J Parenteral and Enteral Nutrition 2012; 36(S1): 68S-75S
5. capsule endoscopy & modern enteroscopy (double - or single balloon enteroscopy, spiral enteroscopy)
6. MRT-Sellink small bowel, CT-Abdomen
Hahn M, Raithel M et al. Moderne Diagnostik der Zöliakie und relevante Differentialdiagnosen bei Getreide-unverträglichkeiten. Allergo Journal 2013 (in press)
serology with celiac disease specific antibodies is only useful, if a sufficient gluten ingestion is present within the last 2-3 months = 0,5-1g gluten/kg b.w. ! adults up to 40 g/day (at least 2 slices of white bread) children up to 15g/day
asymptomatic patients with increased risk of celiac disease conditions for celiac disease screening
• first-degree relatives of celiac disease patients
Kaukinen K et al. Intolerance to cereals is not specific for celiac disease. Scan J Gastroenterol 2000; 35: 942-946
Hahn M, Raithel M et al. Moderne Diagnostik der Zöliakie und relevante Differentialdiagnosen bei Getreide-unverträglichkeiten. Allergo Journal 2013 (in press)
differential diagnoses of celiac disease and intolerance to cereals
IEL, villus atrophy
therapy of celiac disease 1. avoidance of the exogenous trigger (therapy of choice) • gluten-free diet, lifelong
2. modulation of immune response (second choice) only when gluten-free diet fails (refractory celiac disease, type I >> type II) • glucocorticoids • azathioprin, tacrolimus • case reports anti-TNF
e.g. histamine, … 4. new therapeutic developments in future ? • gliadin-digestion (enzymes), synthetic polymers, genetically modified grains • probiotics (VSL 3), improvement of gut barrier, blockage of HLA DQ2/8 • tannins, adstringents coupled with antibodies (IgY) against peptic-tryptic
digested gliadin (glutosin)
how much gluten is gluten-free?
Codex Alimentarius (1st january 2012): „very low gluten content“ </= 100 mg gluten/kg „gluten-free“ </= 20 mg/kg „food products with oats“ </= 20 mg/kg Gluten. at diagnosis and 4 weeks later nutrition counseling and education of patient and family structured dietary advice, food lists of celiac disease society, alternative products should be offered (millet, maize, rice, …)
controversy oats ? - only under medical observation (gastroscopy after 3-6
months and in stable disease
gluten challenge (special situations) oral gluten application, 0,5-1g gluten/kg b.w. adults up to 40 g/d - children up to 15g/d for 2-4-8 weeks
therapy of celiac disease
http://dzg-online.de
eating from internet www.glutenfreigeniessen.de www.querfood.de www.glfparadies.de
bacterial endopeptidases for gluten digestion TTG = Tissue-transglutaminase 2 De Angelis M et al. VSL#3 probiotic preparation has the capacity to hydrolyze gliadin polypeptides responsible for celiac sprue. Biochim Biophys Acta 2006, 1762:80-93 Tennyson CA et al Therapeutic Advances in Gastroenterology 2009