Our next speaker is Jill Olmsted, NP and it's my pleasure to introduce her for our next talk, which will be celiac disease. Jill is an adult nurse practitioner at St. Joseph's Providence Health Hospital in Fullerton, California. She's practiced as a nurse practitioner for about 15 years and specializes exclusively in gastroenterology practice. Jill sees new patients, follow-up visits, and also performs flexible sigmoidoscopy procedures. As you may have noticed over the course of the last day and a half, Jill is an expert coder, certified coder, and she's credentialed in that. And she's also a clinical documentation improvement specialist, and we've talked about the importance of that in our practices. Jill is also a risk adjustment coder. In addition, she's a fellow at the American Association of Nurse Practitioners organization and currently serves on the ASG's reimbursement committee as well. So Jill, welcome. Thanks for doing this. And the floor is yours. Presentation I'd like to go over this morning is on celiac disease. And again, thank you for the planning committee to invite me back again. So other than, yes, I absolutely enjoy, have a passion for coding and billing and clinical documentation improvement, but my day job also is seeing a full-time practicing gastroenterology nurse practitioner. So I have no financial disclosures. And I'd like to go over my polling questions with you first this morning. So after symptom onset, how many years does it take before a patient with celiac disease is actually diagnosed? What is the timeframe that there's a delay in the diagnosis? Excellent. Everyone is wrong except 2% of our audience. So the studies show it takes 12 years before the diagnosis, there's usually a delay in that diagnosis. So it'll be interesting. You'll see, as I go through the slides, the many different symptomatologies that patients with celiac disease can actually present with. So when testing for celiac disease, and a patient who has already started a gluten-free diet, because as you know, is practicing NPs and PAs, patients will already diagnose themselves with this condition before they even see you. So how much gluten do you need to add back into the diet to actually test positive endoscopically or serologically? So it's the A. So three slices of wheat bread daily for one to three months is the recommendation. And these are the guidelines from American College of Gastroenterology for a clinical diagnosis and management for celiac disease. So we'll go ahead and get started. Very good. And I'm going to start with the A. So how much gluten do you need to add back into the diet? So we'll go ahead and get started. Very good. So my objectives today, I'd like to discuss the etiology of celiac disease and review typical and atypical presentations, discuss diagnosis and testing strategies, and review management and surveillance strategies. So the overview, it's a common autoimmune disorder, and it's mediated by damage of the small intestine in response to dietary gluten. And it's results in a malabsorption syndrome. So it'll have an asundery of malabsorption conditions, which just causes a cascade effect. So the incidence is increasing, presenting ages are ages 10 to 40 years of age, and affects approximately 1.4% of our population. There's an increasing incidence in genetically predisposed patients and associated with the HLA DR3 and DQ2 and the DR4 and DQ8 genes. And this is a testing that you can be done for genetically test for celiac disease. 35% of people in the U.S. are carriers of the DQ2 or DQ8, but most never develop symptoms. So the incidence, predominantly individuals in northwestern European descent, and there's an increasing incidence in the first and second degree relatives. So when you have a patient that comes into your office, and their chief complaint is that they have a family history of celiac disease, and they may have some vague GI symptoms, and you would want to test for them for celiac disorder. Siblings, 8.9% incidence, offspring 3.3%, and parents even 3% incidence. So clinical presentations from a gastroenterology perspective, this is where we're going to see our patients. They're going to come in with weight loss, diarrhea, malabsorption, they could have iron deficiency anemia, growth failure, dyspepsia, bloating, or they could even be referred to you by a dermatologist for a rash. It's called the dermatitis herpetiformis. So these are classical symptoms. Non-classical symptoms, which I had mentioned for iron deficiency anemia, you may see that patient, you'd work them up. Also for no sign of GML absorption. So iron deficiency anemia could be osteoporosis, psychiatric disorders, headaches, and elevated liver enzymes. So when you have a patient that comes in for elevated liver enzymes, you want to make sure that celiac disease is one of the conditions that you are testing for. And then a potential positive is that you could have a positive serology test, but your small bowel biopsy is negative. Usually classic, you want to pair the both testing, which is the gold standard. So who should we test? And I went over that with the last schematic drawing. So someone who comes in with classic malabsorption symptoms. So it's going to be your chronic diarrhea, weight loss, fatty stools, postprandial abdominal pain and bloating, malabsorption symptoms. And then, as I mentioned, the iron deficiency anemia, elevated liver enzymes, the dermatitis herpetiformis, headaches, psychiatric disorders, and family history of celiac disease. It's interesting when I meet a patient for the first time who has celiac disease and she's transitioning here, she's transitioning care from a different office practice or relocating from out of state. I'll always ask how long they had symptoms and what were the symptoms that led to them being diagnosed with celiac disease. And it's not uncommon. You do hear symptoms of depression and psychiatric disorders, anxiety, and most of the time it's an astute psychiatrist who is making that diagnosis. So how to diagnosis. So anti-tissue glutaminase, the TTG IgA is the preferred single test. And even the studies show that pediatric societies, if that test is positive over 10 times normal range, then around the age two, then you don't need to do the confirmatory test for the upper endoscopy. Just disclosure, I am an adult practice, so I don't see pediatric population. What's important about ordering your TTG that's immunoglobulin is IgA. You want to make sure you do a serum IgA total, because if your IgA level is low, then you're not going to get a good mediated immune response to mount a response to your IgA mediated testing that you're ordering. So IgA deficiency is actually common also among patients with celiac disease. So then you would reflex to the IgG based testing. So look at, when you go back to work and look at the types of serologies that you're ordering, most of the time you're going to be ordering a celiac panel that will have reflex testing. And usually they'll do either the endomyceal antibody and then reflex to the TTG IgA if that's positive, or you can just order the the TTG IgA with your serum total. So recommended upper endoscopy with duodenal biopsies, even if the serology is negative. And why I wanted to put that polling question out there first about how much gluten do you need to add back in before you do testing, is that patients will come in already having removed all the gluten out of their diet. And when you even mention the fact of adding the gluten back in again, my patients, sometimes they have a look of horror on their face because they feel so much better. And is it really celiac disease or is it gluten sensitivity, which is an overlap of functional bowel syndrome with our patients with irritable bowel syndrome. So there's a lot of negotiating that's done, but more than negotiating, it's patient education explaining to them that for us to make this definitive diagnosis, we really need to add gluten back into your diet. All diagnostic testing should be done, again, on a gluten-full diet. And if on a gluten-free diet, then recommend the three slices of wheat bread daily for one to three months. So the upper endoscopy, the recommendations are one to two biopsies in the duodenal bowel, at least four quadrant biopsies, and the distal duodenum. And the pathology findings show that there's an increased intraepithelial lymphocytes with villus atrophy in the duodenal mucosa. So this is a schematic drawing of the duodenal biopsy. And this shows you a picture of the flattened villi. And this is a picture of what the normal villi look like. They look like finger-like projections that I explained to patients. And if they're into fish or aquariums, then I tell them that it looks just like an anemone. So the little finger-like villi that will move up and down, they're the ones that are absorbing all your micronutrients. I have an interesting story. Many years ago, I had a case where the TTG, IGA, and serologies turned up highly positive, like 15 times above the normal range. The duodenal biopsy, so reflex to upper endoscopy, duodenal biopsies came back negative, no evidence of celiac disease. And I was working with a pathologist at that time to build a slide set for GI pathology, because it's content that we don't usually have in our programs. And I said, you know, Dr. Freeberg, my serology is positive. This is a 99% sensitivity, sensitive and accurate. And I said, could you please review those slides for me? So I have a second pathologist look at it. And as a new nurse practitioner, I mean, it's very intimidating coming into a specialty, nevermind questioning a pathologist report. And he said that, sure enough, when they took the specimen and they blocked it into the wax, they cut, they sliced the wax on a tangential angle. So it looked like the villi were normal. And he said, in fact, when they reread it, then it was positive. There was a villisatropy. So my advice to all of you out there, as Erica even said, is don't just take that one test and believe that and use that as your clinical guidelines, but look at the whole picture. And if something doesn't look right, then have the courage to ask for a second opinion and to revisit that. Histologic findings. So to the left is normal villi. You can see that they're finger-like projections. And then to the right there, the flattened villi, which shows atrophy. And there is a Marsh criteria that the pathologist will use to count the amount of atrophy and the destruction. So moving on to non-gluten sensitivity, similar symptoms, the same symptoms as malabsorption, other than you don't have the micronutrients to back up that you're having a true malabsorption syndrome. So gluten intolerance, you have gas, bloating, and diarrhea. And the recommendations, if evaluation for celiac disease is negative, then trial a low FODMAP diet. So when I work up my patient that comes in with these constellation of symptoms, I'll give them as much information as I can at one time. And I'll say, I want you to have the celiac panel done first. And if it's negative and you receive those results from me, then I want you to try the low FODMAP diet. So these are our patients that come in that haven't started a gluten restricted diet yet. And we have many dietitians that we refer to. I wish we had a program that we had a dietitian embedded into our GI department because there's such a value for having that interdisciplinary interaction. And I wished I would able to just say, I'm going to have, walk you down the hall and have you meet Renee. And she can go ahead and go over some of this information with you. Because studies in the gastroenterology literature tell us that we're not good at diet counseling. We're not good at initiating FODMAP diets. We're not good at starting the diet. And then we start the diet and then we just leave the patients kind of hanging as far as then reintroducing and then personalizing. So I've started to use that verbiage more with my patients. So this is a little overlap with a functional bowel syndrome talk. So take that advice and check that website out too. So management for the patients, you need to consultation with a knowledgeable dietitian. So once you've made that diagnosis of celiac disease, then you need a dietitian to help them with counseling. Now, when do you recheck the patient? So there are studies to show that you can recheck them in six months to see if they're following the gluten-free diet, if they're serologically, they're responding. So you'll see the titers start to come down. And I've had several cases before where their titers stay flat and they, and they don't come down. So I'll refer them back to the dietitian to see if they are having any cross-contamination or any glutenization in the foods that they're eating. Because now everyone thinks that they're eating clean, but once you go out to a restaurant, then it's very difficult to guarantee that they're receiving, you know, absolutely gluten-free food. And what happens is patients come in very distressed in your office because, you know, they want to make sure that they're following a right diet, but other symptoms will come up. And what happens is that you can't always blame the additional symptoms that they're having, GI symptoms, onto celiac disease, because there may be an overlap with functional bowel syndrome. So management is education on the disease process, lifelong adherence to gluten-free diet, identification and treatment of nutritional deficiencies, access to advocacy group, and continuous lifelong follow-up in a multidisciplinary team. So refractory celiac disease, fortunately I haven't had any type of these patients in my office, but this is someone you would probably refer to a tertiary care center. So there's type one and type two, where there's irreparable appearance to the mucosa. Type two results in mortality up to five years. Failure to heal the mucosa can increase the risk for lymphoma, but not mortality. That is conflicting for adults with lack of mucosal healing, mostly do, most do well with that small risk of that non-responsive celiac disease. And then the monitoring, you want to monitor for persistent symptoms and new symptoms. And remember just because they're having new symptoms, you don't want to assume that it's related to the celiac disease or due to non-compliance. Repeat the upper endoscopy with the biopsies, if there is a lack of clinical response, and if there's a relapse despite the gluten-free diet. And then also you want to assess if it's non-compliance to the gluten-free diet as well. Repeat those serologies to verify normalization after six to 12 months on the gluten-free diet and approximately 80% will come back negative. So concurrent disorders that you want to evaluate for, persistent symptoms and or no histologic improvement, if they're lactose intolerant, if they have irritable bowel syndrome, small bowel bacteria overgrowth, which Erica touched on this morning, pancreatic insufficiency, microscopic colitis, which is another one of the differential diagnosis for chronic diarrhea and HIV virus. So patient education, you want to make sure that they're adhering to the diet. So identify if there's non-compliance of the diet, if you're seeing persistent symptomatology, if you're seeing other symptoms of malabsorption, and those are going to be your vitamin deficiencies and look for iron deficiency anemia. And recommend follow-up program, ensure there's adherence to the gluten-free diet and avoid long-term side effects. So practice pearls, we want to provide the best patient education and anticipatory guidance. And I think we can do a better job in having patients come back and follow up. What our department does is we have patients come back every year, but I've seen many patients that re-established with our practice or another practice when they made the diagnosis and then they basically said that they've been left on their own and just told them not to eat gluten anymore. And it can have a long-term effect, especially when these are young people that were diagnosing in their early twenties, this is a lifelong condition. So providing them that anticipatory guidance, I think is key. Ensure that the serologies and duodenal biopsies are performed while ingesting gluten products. Refer to a dietitian at the time of diagnosis and schedule that routine follow-up plan. Give them a follow-up visit. Don't tell them to schedule a follow-up visit if you notice your symptoms of bloating or gas are coming back. To go back to the serologies. So if I explained to my patients that if they're on gluten or if they're not able to come off and their celiac panel is negative, then we'll order the HLA testing. But I'll explain to them that you need to have both copies present to have a diagnosis of celiac disease. You need the DQ2 and the DQ8. If you have one and not the other, then it tells us that you might have it. But if you have both copies, then it's a worthwhile test because then it tells us that you do have celiac disease. Thank you very much.

Jill Olmsted

celiac disease

autoimmune disorder

gluten

malabsorption syndrome