Celiac Disease for the NP Exam

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Celiac Disease for Nurse Practitioner Licensing Exam

Definition

Celiac Disease (CD): A chronic autoimmune disorder triggered by gluten ingestion (found in wheat, rye, and barley) in genetically predisposed individuals. It causes damage to the small intestine, leading to malabsorption of nutrients.

Pathophysiology

Immune Response to Gluten: In patients with HLA-DQ2 or HLA-DQ8 alleles, gluten peptides (specifically gliadin) are deamidated by tissue transglutaminase (tTG). These peptides trigger an immune-mediated attack on the small intestine.

Villous Atrophy: Chronic inflammation leads to destruction of the villi, reducing the surface area for nutrient absorption.
Crypt Hyperplasia: Increased crypt cell production, compensating for villous loss.
Intraepithelial Lymphocytosis: Increased T-lymphocytes in the intestinal epithelium, contributing to inflammation.

Clinical Features

Gastrointestinal (GI) Symptoms

Chronic Diarrhea: Foul-smelling, greasy stools due to fat malabsorption (steatorrhea).
Weight Loss: Due to malabsorption of nutrients.
Abdominal Pain and Bloating: Common due to intestinal inflammation.
Iron Deficiency Anemia: Caused by impaired absorption in the duodenum.

Extraintestinal Manifestations

Dermatitis Herpetiformis: A pruritic, blistering rash on the extensor surfaces (elbows, knees), pathognomonic for celiac disease.
Fatigue: Common, improves with gluten-free diet.
Neurological Symptoms: Peripheral neuropathy, ataxia.

Diagnosis

IgA Anti-Tissue Transglutaminase (tTG) Antibodies: The preferred initial test.

In cases of IgA deficiency, use IgG tTG or IgG deamidated gliadin peptides (DGP).

Small Bowel Biopsy: Endoscopic biopsy showing villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis confirms the diagnosis.

Genetic Testing: Presence of HLA-DQ2/DQ8 can support the diagnosis but is not definitive.

Management

Gluten-Free Diet (GFD): Lifelong avoidance of gluten is the only treatment. Symptom improvement usually occurs within weeks.
Nutritional Support: Supplement iron, calcium, vitamin D, and folic acid to correct deficiencies.
Monitoring: Repeat serologic testing (e.g., IgA tTG) to assess adherence and mucosal healing.

Complications

Refractory Celiac Disease: Symptoms persist despite strict gluten avoidance. Can lead to enteropathy-associated T-cell lymphoma (EATL).
Osteoporosis: Due to malabsorption of calcium and vitamin D.

Key Points

Celiac disease is triggered by gluten ingestion, leading to immune-mediated small intestinal damage and malabsorption.
Diagnosis is confirmed with positive serologic tests (IgA tTG) and small bowel biopsy.
Treatment is a lifelong gluten-free diet with symptom resolution typically occurring within weeks.
Complications include refractory celiac disease, intestinal malignancies, and osteoporosis.