![]() 15 – 39 Most cases of celiac disease are diagnosed in persons with extraintestinal manifestations. Broadly speaking, manifestations can be categorized as intestinal or extraintestinal ( Table 2). The clinical manifestations of celiac disease vary and involve multiple organ systems many patients are asymptomatic or only minimally symptomatic. Finally, it has been suggested that cesarean delivery and rotavirus infection may be risk factors for celiac disease in children. It is uncertain whether introducing gluten in an infant's diet between three and seven months of age would permanently prevent celiac disease or only delay its development. 11 The mechanism by which risk is increased during these age ranges is unknown. Introducing gluten in an infant's diet before three months of age or after seven months of age seems to increase the risk (hazard ratio = 3.98 95% CI, 1.18 to 13.46). 9, 10 There also appear to be two windows of exposure to gluten in infancy that heighten the risk of celiac disease. 9 Furthermore, a longer duration of breastfeeding also seems to decrease the risk of developing celiac disease during the first year of life (odds ratio = 0.66 95% CI, 0.48 to 0.89). Breastfeeding during the introduction of gluten in an infant's diet may decrease the risk of celiac disease (odds ratio = 0.48 95% confidence interval, 0.40 to 0.59). No clear risk factors for celiac disease have been identified for adults, but there are some possible risk factors for children. These patients should be referred to a gastroenterologist for reconsideration of the diagnosis or for aggressive treatment of refractory celiac disease, which may involve corticosteroids and immunomodulators. About 5% of patients with celiac disease are refractory to a gluten-free diet. Dietary education should focus on identifying hidden sources of gluten, planning balanced meals, reading labels, food shopping, dining out, and dining during travel. Treatment of celiac disease is a gluten-free diet. The presence of human leukocyte antigen alleles DQ2, DQ8, or both is essential for the development of celiac disease, and can be a useful genetic test in select instances. Diagnosis is supported by a positive tissue transglutaminase serologic test but, in general, should be confirmed by a small bowel biopsy showing the characteristic histology associated with celiac disease. The presence of dermatitis herpetiformis is pathognomonic for celiac disease. Most cases of celiac disease are diagnosed in persons with extraintestinal manifestations. Common extraintestinal manifestations include iron deficiency anemia, decreased bone mineral density, and neuropathy. Intestinal manifestations include diarrhea and weight loss. Celiac disease is characterized by chronic inflammation of the small intestinal mucosa, which leads to atrophy of the small intestinal villi and subsequent malabsorption. Gluten is a storage protein in wheat, rye, and barley, which are staples in many American diets. It is triggered by exposure to dietary gluten in genetically susceptible individuals. Celiac disease is an autoimmune disorder of the gastrointestinal tract.
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