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ICMR issues draft guidelines on diagnosis & management of celiac disease in India
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Ramesh Shankar, Mumbai
October 27 , 2015
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The Indian Council of Medical Research (ICMR) has issued draft
guidelines on diagnosis and management of celiac disease, which is a
chronic immune-mediated enteropathy that is caused in genetically
susceptible individuals by ingestion of gluten proteins present in
wheat, barley and oats.
Celiac disease (CeD) was originally
described as a disease causing chronic diarrhoea and malabsorption.
Flattening of the villi, inflammatory cell infiltration in the mucosa
and loss of surface area were the major reasons for the clinical
manifestations. The understanding that this is an immune process in
which the intestinal epithelium is damaged is now well accepted.
Following from the original descriptions by Dicke relating wheat
consumption to CeD, a large number of studies have now established the
central role played by proteins from wheat, and to a lesser extent
barley or oats. The disease occurs only in individuals with a certain
genetic predisposition, but at the same time it does not necessarily
occur in all such individuals.
Earlier, the ICMR had created a
Task Force on CeD in 2008, recognizing the need to focus on a disease
that was beginning to be reported in sizeable sections of the population
in several states of northern India. As recommended by the Task Force,
data were collected on the prevalence of celiac disease in three regions
of India through a population-based study carried out in three regions
of the country. The Task Force also recommended that ICMR develop
guidelines for the diagnosis and management of celiac disease in India.
While
several international groups have generated guidelines for the
diagnosis and management of celiac disease, these were largely rooted in
the experience of western countries. There has been considerable
skepticism over the applicability of these guidelines in a country like
India where tropical enteropathy or environmental enteropathy is so
widely prevalent, and where the incidence of parasitic and other
infections of the small intestine is significant.
Celiac disease
classically presents with symptoms of diarrhea and nutritional
deficiencies secondary to nutrient malabsorption. This indicates that
the small intestine is the target organ most commonly affected in
patients with CeD. Small intestinal changes, primarily an increase in
intraepithelial lymphocytes associated with varying degrees of crypt
elongation and villous blunting, form the primary histological hallmark
of CeD. Studies have shown that the intestinal epithelium was the target
of autoantibody deposition in CeD. In the bowel, the proximal small
intestine appears to be the site of greatest mucosal damage as indicated
by the fact that deficiency of iron and folate, which are absorbed
preferentially from the proximal small bowel, are the most common
nutrient deficiencies clinically manifest in CeD. The infrequency of
vitamin B12 malabsorption in CeD shows that involvement of the distal
small intestine is relatively infrequent in CeD.
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TOPICS
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