There are no interventions known to prevent development of CD, although breastfeeding is associated with a 50% reduction in risk when gluten is introduced before the infant is weaned.1,24 Patients presenting with typical symptoms of CD including diarrhea, abdominal pain, and malabsorption should have serologic screening with anti-tissue transglutaminase IgA and/or endomysial antibodies. Testing should be completed before starting therapy. Patients with atypical pelvic pain, particularly with GI components, may also benefit from screening. The current literature does not consistently support silent CD as a cause of unexplained infertility or recurrent pregnancy loss, and routine screening is not recommended. Patients at risk for CD may have HLA-DQ2 and HLA-DQ8 testing.
Patients with negative serology should also be tested for total IgA levels to exclude an isolated IgA deficiency (Figure). After positive serologic screening, endoscopy with upper GI biopsies should be recommended to establish the diagnosis. If confirmatory, a gluten-free diet should be advised.
Because adherence to a gluten-free diet is difficult and requires a lifelong commitment, both patient and physician should have clear expectations for potential benefit at the outset. Pregnant patients and those planning to conceive in the near future can expect to reduce the risks of preterm delivery, low-birth-weight infants, and IUGR associated with overt CD. Patients known to have CD should expect to have near-normal fertility potential with appropriate diet, but the benefits of adopting a gluten-free diet in patients with silent CD are unproven.
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