Celiac disease, new national guidelines presented
Diagnoses of celiac disease are increasing: there are currently 245 thousand confirmed cases in Italy, but it is estimated that the real numbers are closer to 600 thousand, considering the often asymptomatic onset of this pathology. At the same time, fortunately, the prognosis also improves. With correct management of therapy, which in this case consists of a gluten-free diet, the complications of celiac disease can almost always be avoided, especially when it is detected early.
It is precisely for this reason that it is important to raise awareness among the population of the symptoms of the disease, and of doctors on the correct procedure for the diagnosis, treatment and follow-up of patients. A precious opportunity in this sense are the brand new ones national guidelines developed by the Italian Society of Gastroenterology and Digestive Endoscopy (SIGE), in collaboration with other scientific societies, presented today to the Senate.
The document is part of the series of four guidelines published by the Istituto Superiore di Sanità, and dedicated to celiac disease, acute pancreatitis, diverticulosis of the colon And infection by Helicobacter pylori. Four documents addressed to family doctors, paediatricians and other specialists, which concern four of the most common pathologies in the gastroenterology field, and which have recently been included in the National Guidelines System of the Istituto Superiore di Sanità.
An increasingly common disease
“Celiac disease is a chronic disease of the small intestine, due, in genetically predisposed individuals, to the consumption of gluten, the protein mixture of wheat and other cereals”, he explained during the presentation event Federico Biagiprofessor of Gastroenterology at the University of Pavia, among the editors of the Guidelines.
“It causes atrophy of the intestinal villi and consequent reduction of the intestinal absorbent surface and therefore reduction of the absorption of ingested nutrients. It is very frequent in the general population and in some cases (<1%) complications arise. Over the last twenty years the prognosis is however much improved."
The credit can certainly be attributed, at least in part, to a better diagnostic ability on the part of doctors. And to the now acquired awareness that the problem is not limited to the pediatric field, as it might have seemed until a few decades ago, but can begin, or in any case become symptomatic, at any stage of life. Celiac disease is often practically asymptomatic, and in many cases the symptoms appear with related diseases, such as osteoporosis or anemia, which can mislead doctors and patients who are not sufficiently informed about this pathology.
The diagnosis
Knowing celiac disease is therefore essential to guarantee timely diagnoses for all patients. It starts with a clinical suspicion, often intercepted by the paediatrician, the general practitioner or even the rheumatologist, which must be investigated in depth with the correct serological tests. “In case of suspected celiac disease and therefore in the presence of symptoms, associated autoimmune pathologies or even just family history, a blood sample for the search for anti-transglutaminase IgA antibodies, associated with the measurement of total IgA immunoglobulins, will indicate whether to perform the biopsy intestinal for the evaluation of atrophic intestinal damage,” he explained Fabiana ZingoneGastroenterologist and professor at the University of Padua and editor of the Guidelines together with Biagi.
In this phase – the experts who spoke at the presentation of the new guidelines underlined – it is essential not to eliminate gluten before having completed the diagnostic process, because those who rely on the advice of friends, relatives, or uninformed doctors, and begin the diet at the onset of the first symptoms unnecessarily complicates the diagnostic process, with the result of arriving late (or perhaps never) at an official diagnosis.
“In any case, it is important to contact a regional reference center for celiac disease for the correct interpretation of the results,” added Zingone. “For children, in the case of very high antibodies, it is possible to avoid intestinal biopsy, but this strategy must be decided only by pediatricians from reference centers for celiac disease. An international study, coordinated by Italy and recently published, demonstrates that the diagnosis strategy without biopsy is also applicable, in selected cases, to the adult population. In the near future, it is therefore possible that this approach will also be used in a subgroup of adult patients”.
Therapy
Once the diagnosis is made, therapy begins, which for celiacs consists of a completely gluten-free diet. Patients must therefore eliminate all foods derived from wheat, barley and rye. Without allowing mistakes or transgressions. But at the same time – Biagi recalled – without bordering on paranoia: a dose of less than 50 milligrams of gluten per day is tolerated by the body, and therefore it is useless to fear accidental contamination of food.
On the drug front there is no news for now, but research is at work, and several promising molecules, most likely dedicated to patients (fortunately rare) who continue to suffer from the symptoms of the disease despite adopting a gluten-free diet , could give the desired results already in the next few years.
“The targets are different: from the digestion of the toxic fractions of gluten to the inhibition of some stages of gluten-related inflammation”, said Zingone. “Some of these studies are also underway in some Italian centers. The results seem promising for some drugs, but we will have to wait for further results in order to define the target population and the methods of use in clinical practice.”
Guidelines to be disseminated
Rossella Valmaranapresident of the Italian Celiac Association (AIC), who spoke during the event, welcomed the publication of the new national guidelines, recalling at the same time the importance of making the document known throughout the Italian territory, to guarantee equal access to adequate diagnosis and treatment throughout the peninsula.
“More important than the document is its dissemination in local facilities, but also in basic medicine, to guarantee all patients the right to diagnosis and treatment and correct follow-up”, concluded Valmarana. “The Association continues to collect the stories of patients who struggle to reach the diagnosis of celiac disease because the doctor does not recognize predictive symptoms other than the classic ones, because the patients are put on a diet by the general practitioner or specialist before having once the diagnostic process is concluded, because the test is done once and never repeated again. Collaboration with scientific societies is a statutory purpose for the Association, we are happy to give our availability to the widest dissemination of the Guidelines , in every direction you suggest.”
