Response

Treating the symptoms of a patient without an attempt to make a diagnosis is bad medicine. For instance, one should not treat a 12-year-old boy with iron deficiency anemia with oral iron supplements. The cause of anemia must be established first. Although the ultimate goal of any therapy is to alleviate patients’ symptoms, this must be done in the context of a clinical diagnosis. Celiac disease is a good example of such a practice.

The fact that abdominal pain or bloating improves with a gluten-free diet is no proof that the patient is suffering from celiac disease. Dietary therapies can have a substantial placebo effect in many gastrointestinal disorders. It must be remembered that celiac disease is a permanent sensitivity to gluten and the diet must be strictly gluten-free—forever—with no exceptions. Gluten sensitivity is not analogous to lactose intolerance, which is a noninflammatory, dose-related problem. Celiac disease is an all-or-nothing phenomenon: an individual either has it or does not. Even small amounts of gluten can cause intestinal mucosal injury. If this goes unchecked, the patient is at risk of developing serious complications like osteoporosis and cancer.

It is common for the physician (or individuals themselves) to put the patient on a trial gluten-free diet based on symptoms alone. The symptoms might improve; however, the patient soon realizes that a strict gluten-free diet is not easy to follow. The diet is costly, complex, and socially restrictive. Now the patient wants to know if celiac disease is truly present so that he or she can liberalize the diet, and a referral is made. Those of us who work in the field know how difficult this situation is for the patients, their families, and gastroenterologists.

The focus should be on improving awareness of celiac disease and advocating wider availability of serologic screening and timely access to endoscopy, rather than empirical therapy of this lifelong disorder.

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