Etiologies and predictors of diagnosis in nonresponsive celiac disease.
OBJECTIVE
Nonresponsive celiac disease (NRCD) is a common problem affecting from 7% to 30% of celiac patients. Because NRCD comprises varied and potentially morbid entities, efficient and cost-effective patient care requires knowledge of the specific causes of this disorder. The aim of this study was to determine the common etiologies of NRCD in a tertiary referral center.


METHODS
All cases of biopsy examination-proven celiac disease (CD) seen at our institution over the preceding 5 years were included in this study. NRCD was defined as a failure to respond to at least 6 months of treatment with a gluten-free diet or the re-emergence of symptoms or laboratory abnormalities typical of CD while still on treatment with a gluten-free diet.


RESULTS
A total of 113 patients with NRCD meeting the earlier-described criteria were seen from a total of 603 patients with CD (19%), however, among patients for whom we provided primary specialist care the incidence of NRCD was 10% (P < .001). Gluten exposure was the most common cause of NRCD (36%), followed by irritable bowel syndrome (22%), refractory CD (10%), lactose intolerance (8%), and microscopic colitis (6%). The mean immunoglobulin A tissue transglutaminase level in the gluten-exposed group was 67 vs 17 U/mL (normal, <20) for other diagnoses (P < .05). Weight loss and male sex were highly predictive of refractory CD (P < .05 and < .001, respectively).


CONCLUSIONS
NRCD is a common phenomenon affecting 10%-19% of celiac patients. A limited number of etiologies account for the majority of cases. Clinical factors may be used to guide evaluation.
Leffler
Daniel A
DA
Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA. dleffler@caregroup.harvard.edu
Dennis
Melinda
M
Hyett
Brian
B
Kelly
Eoin
E
Schuppan
Detlef
D
Kelly
Ciaran P
CP
D000328:Adult; D000367:Age Factors; D001707:Biopsy, Needle; D002446:Celiac Disease / Q000175:diagnosis* / Q000178:diet therapy / Q000209:etiology*; D046728:Colitis, Microscopic / Q000150:complications*; D016099:Endoscopy, Gastrointestinal; D001068:Feeding and Eating Disorders / Q000150:complications*; D005260:Female; D005983:Glutens / Q000009:adverse effects; D006801:Humans; D015994:Incidence; D007413:Intestinal Mucosa / Q000473:pathology; D043183:Irritable Bowel Syndrome / Q000150:complications; D008297:Male; D011237:Predictive Value of Tests; D011336:Probability; D011379:Prognosis; D012008:Recurrence; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012737:Sex Factors; D017211:Treatment Failure
D005983:Glutens