The presentation that I'd like to go over with now is celiac disease and other small bowel disorders, and what I did was I highlighted small intestinal bacteria overgrowth. I have no financial disclosures. So I'm going to start off with two polling questions. After symptom onset, how many years does it usually take for the diagnosis of celiac disease to actually be made so what is that time delay. Actually it's 12 years. It takes a lot longer for us to have this on our radar to start figuring out to order the test. Next polling question. When testing for celiac disease in a patient who started a gluten free diet so they've already identified that they have some type of gluten sensitivity and they're going to take gluten out of their diet on their own. How much gluten Do you think you should add back into the diet before testing, either endoscopically or serologically. Actually you need more gluten in your diet so the answer is three slices of wheat bread for approximately one to three months. Now when, when you're sharing this with your patients, they don't want to go back on any gluten at all, so we can talk about that a little later how you can negotiate with the patients and maybe have it stretch out a little bit longer. So the objectives I'd like to go over is the ideology of celiac disease we're going to go over the typical and atypical presentation. We're going to look over management and surveillance strategies and then discuss diagnosis of management of small intestine bacterial overgrowth. Celiac disease is a common autoimmune disorder mediated by damage of the small intestine in response to dietary gluten. This results in a malabsorption syndrome. And you're going to find that there are many different symptoms that patients may present to you so it's something that we always have to keep on our radar. The incidence is increasing, is increasing, and it's presenting between the ages of 10 and the age of 40 years of age. It affects 1.4% of the population. The incidence in genetically predisposed patients that's associated with HLA-DR3 and DQ2 and DR4-DQ8 genes. 35% of people in the US are carriers of DQ2 or DQ8, but most never develop the symptoms, that's why it's important if you do need to genetic testing and it is to explain to patients that they need to have both the DQ2 and the DQ8 gene present to make the diagnosis. Predominantly individuals in the northwestern European descent, there's an increased incidence in first and second symptoms. So sometimes I'll see patients in my office, adults, that their, their child, their, their daughter, their son was recently diagnosed, so they're coming in for testing. So siblings is an 8.9%, offspring 3.3%, and parents 3%. So the classical presentation, we're going to go over classical, non-classical, and potential, is weight loss, diarrhea, malabsorption, growth failure, dyspepsia, bloating, and dermatitis herpetiformis. Now other than the dermatitis herpetiformis, you can see that the classic symptoms are presenting, could be a malabsorption syndrome, could be chronic diarrhea, could be related to irritable bowel syndrome. You'll see the American College of Gastroenterology guidelines for working with patients with IBS, predominantly with diarrhea. Recommendations are to order a CNAC panel and a stool test for Giardia. So those are clear that you need to have that part of your workup as a minimum when you're seeing a new patient that you think they may have functional bowel disorder, but you still want to rule out other causes and etiologies. Now, non-classical symptoms that you see is that there's no sign of GI malabsorption. I've seen patients before with iron deficiency anemia, also secondary osteoporosis because of the malabsorption syndrome for the vitamin D. I've seen patients that have told me the story. So I haven't, I'm not in a primary position system in gastroenterology to be that first line person for someone that comes in with a psychiatric disorder, but I have had patients tell me a story or tell me their story. How did you first come about being diagnosed? And I had one patient tell me that she had bipolar disorder. She was diagnosed for 20 years. Her primary care doctor tested her for celiac disease and she was positive and the gluten-free diet, her going on and being managed changed her psychiatric profile. I had another patient that told me that she was an introvert. And then after, and after she was diagnosed, she became an extrovert. She had different types of ambitions, different interests. And she said to me, she goes, Jill, I kind of, I wonder what type of person I would have been if I was diagnosed earlier than when I was in my formative years. And, you know, in my, in my twenties and thirties, when I had chose a job career, when I had chose to partner in my life, and that's always made me pause realizing that celiac disease has such a impact in every different disease process. And there are situations where you can have a positive serology. So your blood work is positive. That shows that you have positive tissue transglutaminase levels, but your small bowel biopsies are negative. So that's when you have to really counsel your patients and make sure that they are having some gluten in their diet every day as you lead up to that small bowel biopsy for the endoscopy. So who should be tested? So someone with chronic diarrhea, weight loss, statatoria, postprandial abdominal pain, bloating. I see a lot of bloating in my, in my department, chief complaint, bloating, bloating for five years, 10 years. So this initiates your workup. Iron deficiency, anemia, elevated liver enzymes. I know we had a question earlier on is how much of that big shebang do we order for patients with elevated liver enzymes? Well, celiac panel is one of the tests that I order. If I see a new patients with elevated liver enzymes. Dermatitis or pediformis. So you may be getting this referral from your primary care or from a dermatologist. Patients with headaches, psychiatric disorders, or family history of celiac disease. So how to diagnose. So the TTG is the test that you're ordering is Ig, is immunoglobulin IgA based. It's the preferred single test if you're over the age of two years old. Now what's important is that you want to include a serum total IgA because if your IgA level is low, then you're not going to have an appropriate response and be able to depend on that IgA results. So if you, if you are IgA deficient, then you want to use IgG based testing. Now it's interesting, there is a high percentage of population of patients with celiac disease that do have IgA deficiency. I had a patient just last week that her IgA level I think was 10 and normal ranges in the hundred range. And I also referred her to an immunologist for evaluation. So IgA deficiency is infrequent, but it's an important reminder that your IgA isotype testing can be negative. So we talked about that. So the recommendation would be measuring your total IgA levels, but next step you reflex to is your IgG deaminated gliadin antibody, and then the TTG IgG testing. We do recommend as a gold standard upper endoscopy and do a dental biopsies, even if the serologies are negative, and that's going to be based on your symptomatology. All diagnostic testing should be done while patients on a gluten full diet. And this is hard negotiating this with patients. So the answer to the question was three slices of wheat bread daily for one to three months. AGA had written that if you can challenge a patient with one slice of bread, which is 4.8 grams a day, at least for two weeks, then you may be able to get a response. It's just so hard to work with your patients if you don't make that original diagnosis. I think in my career, I had one patient that swore she would not go on gluten for me. And her HLA testing was inconclusive and her endoscopy test was negative. So it's that type of patient that you would just continue to monitor. But our patients that are gluten intolerant are very, how do I say, passionate about not wanting to have any gluten back in their diet because they feel so much better. So recommendations are one to two biopsies in the duodenal bulb. You want to have four plus biopsies in the distal duodenum. And what we're looking for is increased intraepithelial lymphocytes, and you're looking for that villus atrophy of the duodenal mucosa. Because what gluten does, it causes an autoimmune disorder where it actually destroys the villus in the duodenum, which is where you're absorbing your fat soluble vitamins. And if you think about the villi, I always think of a sea anemone, the little finger like projections that are kind of floating along in the duodenum, and those actually get blunted and which then causes this malabsorption syndrome. Here's a picture that you can see from a wax paraffin biopsy result. On the left is the normal villi, and on the right you see this flattened villi which causes that atrophy. One of the classifications that they'll use is the Marsh criteria. So non-celiac gluten sensitivity is a real thing. So people who are gluten intolerant can have gas and can have bloating and diarrhea. And if the evaluation for celiac disease is negative, then I try patients on a low FODMAP diet. I will utilize the assistance of a dietician to help me work through this process, and I'm emphatic with patients to let them know that this is a test. They're going to look to see what potentially you could be sensitive to, and I'll give them information on the low FODMAP diet. I'll start off not with a strict elimination, but I'll say, go over this diet and just see what type of foods that are in your diet on a regular basis. And then, of course, don't forget the basics. Don't forget to go over with your patients, are you consuming any artificial sweeteners? Because that's one of the number one that can cause gas and bloating as well. Artificial sweeteners that can infiltrate your diet. Also, citric acid, and you find citric acid in the lemonades that patients drink or the vitamin waters, those little packets that you can purchase and make your flavored waters. Also, citric acid is found in crackers. So there are different foods that can find their way into other daily foods that they may be snacking on. So you start the low FODMAP diet and you want to reintroduce, then start to slowly reintroduce foods and then personalize. And I'll be candid with patients and say, you know, we're not good at this. We're not good at following your diet. We're not good at assisting with helping you reintroduce foods, and we're not good at helping you personalize. I said, that's why we have the assistance of a dietitian to help us. And this is not a diet that is meant for you to be lifelong on it. And I've had patients come back in my office and what happens is they become very restrictive in their diet, they start to lose weight and then you start to have concerns about other issues. So it's absolutely important to get their buy-in, to get an assistance with a dietician to help you work through this process. And I have a link here for the Monash FODMAP diet. That's a great resource. So management, you want consultation with a knowledgeable dietician. Every once in a great while, my patients will say, well, why do I have to go to a dietician? I'd rather just talk to you, Jill. So you have to navigate through those challenges. These patients take a lot of time and it takes a lot of energy to help patients go through this process. What I do do in my practice though, just to get a snapshot of what my patients are eating is I'll ask them to give me a 24 hour diet recall. So I'll say, okay, yesterday, tell me everything you ate and drank. We'll just start with breakfast, lunch and dinner and snacks and you really get a bird's eye view of what a patient's nutritional habits are like. And then you'll find out, did they have a healthy breakfast in the morning? Did they have an egg? Did they have spinach with their egg? Did they have maybe a half a slice of wheat toast or did they go to McDonald's and have an egg McMuffin? So I also learned that I have to counsel patients about processed foods and fast foods before you even go into your low FODMAP diet because those are foods are also that are going to be causing the gas and bloating as well. So doing that 24 hour diet recall gives me so much information just to help with counseling for healthy dietary habits. Education for the disease process, lifelong adherence to a gluten-free diet. We're gonna identify and treat nutritional deficiencies and then access to advocacy group and then continuous long-term follow-up multidisciplinary team. So I had a patient recently, she and I were following up with each other and she was telling me how she identified some information on one of her face group books. And I said, face group books? I said, what ones are you on? She goes, oh, I'm on about five of them. She was, they're great. And they're all about celiac disease. And they're all about support groups. And she actually gave me some information that I wasn't aware of. Oh, I know what it was. So she was telling me how, cause we were talking about how gluten is in medications. And a lot of times when I'll see patients who were not able to figure out why their celiac panel is not coming back normal because they're swearing to me like, Jill, I promise I'm not eating any gluten in my diet. Well, if you look at different medications then they can harbor gluten. And what you wanna do is you wanna look at the medication and see if the word is starch there. And not only is it medications, but it is in cosmetics. Some of the items that came up, she said Blistex also has gluten in it too. But you're not gonna find the word gluten, you're gonna find starch. Okay, so refractory celiac disease. There are different types, there's type one and type two. And this is a irreparable appearance to the mucosa. Type two results in a mortality up to five years. This is serious. Failure to heal the mucosa increased risk of lymphoma, but not the mortality. And there is, data is conflicting for adults as far as this lack of mucosal healing, mostly do well with small risks for non-responsive celiac disease. Fortunately, I haven't seen this before in my practice. I think last year there was one of our attendees had shared that he did have one patient that they sent to a teaching facility to take care of this problem, but it's not something that I see commonly. And fortunately, I hope none of us see this commonly. Again, monitor for persistent new symptoms, repeat upper endoscopy with biopsy, especially if there's a lack of clinical response. You're gonna do blood testing and you're gonna see the serologically whether they're adhering to that gluten-free diet. But just as I gave you that real life experience just a minute ago about a patient who, you know, identified that gluten was kind of squeaking in through cosmetics and a medication she was on. So repeat those serologies to verify normalization after six to 12 months on a gluten-free diet and approximately 80% will test negative. So concurrent disorders, persistent symptoms or no histologic improvement. Think about lactose intolerant. So that's another product you wanna take out of the diet. Think about diagnosing with irritable bowel syndrome, mostly diarrhea predominant, small intestinal bacteria overgrowth, microscopic colitis, which you'll hear about later on this afternoon and human immunodeficiency virus. So patient education, again, look at their diet, see if those vitamin deficiencies are persistent, anemia and recommend that referral to the dietician. My patient told me that there's apps that you can download that will have a barcode scanner where you can put it over your food products to see if there's gluten within that product. But again, this is gonna be a processed food and avoid long-term side effects. So small intestinal bacteria overgrowth. The clinical syndrome is excessive bacteria in the small bowel. It causes malabsorption of nutrients, altered intestinal permeability. Inflammation is an immune activated response from bacterial fermentation in the small bowel. Symptoms are bloating, gas, diarrhea, constipation, abdominal pain. Doesn't this sound like a multitude of other conditions that we see in our office? So diagnostic testing, there are breath tests to assess for glucose hydrogen or lactulose hydrogen. The test that we use, it's a proprietary test, it's called TrioSmart, and it measures three gases. It's measures hydrogen, methane, and hydrogen sulfide. So the disorders associated with SIBO are multitude. You have a mechanical cause, which could be post-surgical causes. So if I have a patient that comes in that they've had abdominal surgery and they're complaining of gas and bloating and distention that's significant from previous history, even if there is an overlap with IBS, then SIBO is something that I will consider about testing. And I think the caveat I have with all these multitude of testings that we recommend for our patients, as Joe was saying in the kickoff of our first presentation, we have this differential diagnosis. We have this list of things that potentially we could order for our patients. Well, if I'm seeing a patient for the first time, then ordering that stool studies and the celiac panel and referral for the dietician, do I order a TrioSmart breath test at that same time? No, I don't, because I kind of want the dust to settle and see what this information is going to show to me. Sometimes I'll start addressing it, but then sometimes patients will already bring that to the table even the first time that they meet you. A lot of times they'll just, the whole point of their first initial visit is that they want to be tested for SIBO without even anything else precursing to that. So you have to navigate through that information. Systemic diseases, motility disorders can cause it. Medications, how many patients do we see on opioids that have a dysmotility disorder? Proton pump inhibitors are even implicated in increased risk for SIBO. Malabsorption syndromes, and even their aging population. So symptom management, I mean, symptoms are abdominal pain, diarrhea, constipation, dyspepsia, and bloating. If it's diagnosed as, so two different pathways, you've got hydrogen, hydrogen sulfide, which is diagnosed with small intestinal bacteria overgrowth, and that's going to be diarrhea predominant. Management for it is rifaximin, 550 milligrams, TID for 14 days. There's about a 61% to 78% efficacy. You absolutely need to engage a dietician to help with a low FODMAP diet. You don't want to have patients on the low FODMAP diet while they're being tested, because the theory is that you want these bacteria to be proliferating and to be in an abundance to make the diagnosis. There is also an elemental diet. Some patients don't want antibiotics for this treatment. So there is an elemental diet, which is very basic, very restrictive, and expensive. And I should have put a link on that, but that's something that you can even search yourself if that's something that patients want to explore. There's also some herbs, series of herbs that have also been shown to help with the eradication of SIBO as well. The next pathway is methane. So you have IMO, or intestinal methanogenic overgrowth, which they say is not really a bacteria, it's an arcane, it's a different type of species. And boy, oh boy, when you start doing literature research on SIBO, you're going to open up a whole new world of small ball bacteria overgrowth, and you're going to realize that we're just being controlled by bacteria. We have no say in what we do. So the treatment for that is constipation. I mean, the symptom of that is constipation, and the management is a combination of neomycin or rifaximin. So a quick case presentation, 45-year-old female with IBSD. She's had it for over 20 years, bloating, diarrhea. You've known her for a long time. She had a recent workup by your colleague. There were biopsies that were done that were negative, stool studies that were done that were negative, fecal fat was negative, pancreatic elastase was negative. Five years ago, she had a partial colectomy due to acute diverticulitis with a microperforation. So you're looking through her record, and we all find ourselves in this situation. We come in, we haven't seen the patient for a while. It's like, what has been done? What hasn't been done? So you find that she needed a celiac panel done, and then you want her to restart the gluten products. And you said to her, okay, if this is negative, then let me go ahead and order a SIBO breath test. So serologies, the tissue transglutamine AIGA 100, reference range is less than 100, so the antibody was not detected. Your immunoglobulin IGA was 200, so that's a normal reference range. So here you go, you have made the diagnosis for celiac disease in this patient. And here she's had bloating and diarrhea for 20 years. So you recommend an upper endoscopy with a small bowel biopsy to rule out celiac disease, and it's confirmative. You've got this increased intraepithelial lymphocytes. So you give her guidance and counseling, and you refer her to a dietitian, and she starts a gluten-free diet. You repeat the serologies in six months, and she has converted back to normal range. So practice pearls. Provide patient education and anticipatory guidance. Ensure serologies and duodenal biopsies are performed while they're ingesting gluten products. Refer to your dietitian at the time of diagnosis. Look for those hidden gluten products and cosmetics and medications, and then absolutely schedule routine follow-up visits and plan your patient. Map them out on how often you want to keep an eye on them and retest them, and that way you maintain a good, close patient relationship. And there are my references. And thank you.

celiac disease

small intestinal bacterial overgrowth

gluten-free diet

nutritional deficiencies

breath tests

rifaximin