Should Intestinal Healing Be Assessed in Treated Celiac Patients?

Response from Bret A. Lashner, MD
Professor of Medicine, Cleveland Clinic, Cleveland, Ohio

The mortality rate of patients with celiac disease is only slightly elevated compared with that of the general population. Most of the excess mortality in these patients, however, is from the increased risk for enteropathy-associated T-cell lymphoma. Because risk for lymphoma is believed to be directly related to untreated celiac disease, it would be reasonable to monitor patients with celiac disease for adherence to a gluten-free diet. Although no formal guidelines exist, ordering an annual celiac panel (tissue transglutaminase and endomysial antibodies) would be reasonable. Elevated titers of these antibodies could implicate the patient in being nonadherent to a gluten-free diet.

A recent study showed that serologic testing closely correlates with level of mucosal healing on biopsy. Because serologic testing is easier to obtain and less expensive than small-bowel biopsies, I think that serial serology measurements would be the best way to monitor patients with celiac disease. In a minority of patients, serologic measures will not improve on a gluten-free diet. These patients should be recounseled by a dietitian on the nuances of the gluten-free diet. In light of recent evidence that even foods believed to be naturally free of gluten (such as rice and millet) can be contaminated with gluten, people who believe they are following a gluten-free diet might have more gluten exposure than they realize. At this point, I do not believe that imaging studies or biopsies are necessary and are not likely to be cost-effective.

In patients whose celiac disease is truly refractory to a gluten-free diet, alternative diagnoses, such as collagenous sprue, amyloidosis, sarcoidosis, and other infiltrative diseases of the small bowel, should be ruled out with repeat biopsies and special stains, and then alternative therapies should be initiated.