The First MEDICEL Meeting Following ESPGHAN PROTOCOL REVISION

First Objective of the Project “Capacity building and development of guidelines for the care

Guidelines for Public Health and Clinical Practice of Celiac Disease • Definition Gluten induced

• Public Health Issues ØMost affected go undiagnosed: they bear a considerable load

WHEN CELIAC DISEASE SHOULD BE SUSPECTED in CHILDREN and in ADULTS: • Growth failure

FIRST LINE OF DIAGNOSIS Point of care assay of Anti TGASE Antibodies COMPLETE DIAGNOSTIC

• Biopsy ØRequired for most cases ØIt may be avoided in cases with

DIETARY TREATMENT üRice, Maize, potatoes, Millet, Sorghum, legumes and vegetables as basic sources of

FOLLOW UP Give support to sustain compliance to the gluten free diet during the

CELIAC DISEASE SUSPECTED POINT-OF-CARE SCREENING OF ANTI-TGASE NEGATIVE LOOK FOR OTHER DIAGNOSIS POSITIVE BUT…IF

POSITIVE: confirm by serology Positive serology serolog TGASE >50 + severe symptoms Negative serology

COMPLEX CASES Refer to the MEDICEL network

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The First MEDICEL Meeting Following ESPGHAN PROTOCOL REVISION 2010 European Laboratory for Food Induced Diseases (ELFID) University of Naples Federico II Cairo 30 th April to 1 st May Prof. Luigi Greco Dr. Laura Timpone

First Objective of the Project “Capacity building and development of guidelines for the care of food induced disease in infants and children”

Guidelines for Public Health and Clinical Practice of Celiac Disease • Definition Gluten induced Autoimmune Disease • Prevalence From 1% to 2% of Mediterranean Population: estimated 4, 5 to 9 million cases over 450 million population

• Public Health Issues ØMost affected go undiagnosed: they bear a considerable load of disease and sufferance. ØThe risk to die is at least doubled and is significantly increased in children exposed to poor nutrition and infections ØUndiagnosed Celiacs require significant amount of Health Services and Facilities ØGrowth failure in children and misery in adults limit the pool of human resources in a country

WHEN CELIAC DISEASE SHOULD BE SUSPECTED in CHILDREN and in ADULTS: • Growth failure or weight loss • Persistent Gastro Intestinal symptoms • Irritable Bowel and other “functional” G. I. symptoms • Anemia • Misery • Other Autoimmune Disease (Diabetes, Thyroiditis, etc) • Unfavorable pregnancy or infertility • Relatives of known Celiac cases: they have a 10% risk • Think about celiac whenever you do not reach a clear diagnosis

FIRST LINE OF DIAGNOSIS Point of care assay of Anti TGASE Antibodies COMPLETE DIAGNOSTIC WORKUP Ø Serological evaluation of Anti TGASE Ø Small Intestinal Biopsy Ø Evaluation of HLA DQ 2/DQ 8: § to support the diagnosis in complex and unclear cases § to exclude the diagnosis in relatives of CD cases

• Biopsy ØRequired for most cases ØIt may be avoided in cases with very high anti TGASE titers (>50 RU) and overt unequivocal gluten related clinical manifestations ØBy endoscopy with sedation

DIETARY TREATMENT üRice, Maize, potatoes, Millet, Sorghum, legumes and vegetables as basic sources of carbohydrates üAvoid gluten containing foods, no other restrictions üStimulate the selection of locally available traditional gluten-free foods üAvoid gross contamination with wheat , barley or oats flour

FOLLOW UP Give support to sustain compliance to the gluten free diet during the first year, possibly every 3 months (also by phone) Clinical Evaluation once a year

CELIAC DISEASE SUSPECTED POINT-OF-CARE SCREENING OF ANTI-TGASE NEGATIVE LOOK FOR OTHER DIAGNOSIS POSITIVE BUT…IF THERE ARE SEVERE CLINICAL CONDITIONS CONFIRM BY SEROLOGY

POSITIVE: confirm by serology Positive serology serolog TGASE >50 + severe symptoms Negative serology TGASE <50 BIOPSY Positive CELIAC DISEASE START GLUTEN FREE DIET Check Clinic and by locally available food stuff Compliance to diet every 6 months BIOPSY Negative Exclusion of other causes Clinical follow-up and TGASE every 6 months

COMPLEX CASES Refer to the MEDICEL network