Dr. Robert Pastore, PhD, CNS


Celiac Disease: A Clinical Chameleon

2019-08-196 min read

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Celiac disease is a serious autoimmune disease that is not receiving the attention it should by many medical professionals and even the National Institutes of Health. It can act as a clinical chameleon, eluding diagnosis, and this has resulted in the average time to diagnosis being ten years, which I refer to as the “decade to diagnosis.” Here are some startling facts.

  • Data suggests 83% of those with celiac disease are undiagnosed.
  • Prevalence in the general population is 1 out of 100 but increases to 1 out of 10 if there is a relative with the disease.
  • The incidence in the United States has doubled every 15 years since 1974.
  • There is a 2 to 4 times increased risk in coronary artery disease and small intestinal cancer for those with celiac disease over the general population.
  • There is an increase in all-cause mortality for those who are undiagnosed.
  • Currently, the ONLY accepted treatment is a strict life-long gluten free diet, but data is indicating inadvertent exposure to gluten from certain prescription medications, cross-contamination and the contamination of foods routinely thought of as being gluten free.

While those facts can be alarming, for me the true story goes back to the clinical aspects of the disease, the delay in diagnosis and how it presents to the medical professional in practice. Often symptoms are vague, outside of the gastrointestinal tract, and cause the physician or even specialist to either not consider celiac disease as a possibility, or an incomplete diagnostic panel is undertaken, which can result in misdiagnosis.[6][7][8][9][10]

Deepening this story is the strong potential that the physician may not be fully aware of the nuances of celiac disease testing and result in continued patient suffering and the decade to diagnosis. McCormick and colleagues presented this potential issue at an American College of Gastroenterology conference and Assiri and colleagues and Zipser and colleagues discovered similar findings.[10][11][12] For example, for many doctors an IgA tissue transglutaminase antibody analysis could be the first and only blood test used to determine risk in a patient. Yet, a selective IgA deficiency has a rate of occurrence 10 to 15 times more frequent in celiac disease patients than their non-celiac counterparts.[13] With that in mind, if testing a single IgA based gluten test, it is wise for physicians to measure total serum IgA first, because that should dictate the correct testing course of action. An IgA deficiency renders the most popular initial blood test screening moot and physicians should consider other serology, measuring gliadin DGGL gliadin deaminated IgG antibodies.

There are some options for serology testing for the potential celiac disease and should be selected on unique requirements of the individual patient. These tests include tissue transglutaminase IgA and IgG, DGLDN gliadin deaminated antibodies IgG and IgA, endomysial antibodies IgA as well as celiac associated HLA-DQ alpha 1 and DQ beta 1 medium high-resolution DNA typing.[14] The goal of any tests for celiac disease risk is to identify if a biopsy is required, which is the gold standard for celiac disease diagnosis in the United States.[15]

In other cases, uncommon symptoms may actually be the dominant ones presenting in clinical practice. They were for me and contributed in my more than a decade to diagnosis. Referencing the aforementioned work by McCormick, Assiri, Zipser and their respective colleagues, not all health care practitioners may be aware of all the associated symptomatology. Take a look at an example of classic symptoms and non-classic symptoms and manifestations below.

Classic Symptoms and ManifestationsNon-Classic Symptoms and ManifestationsPediatric Presentation (>2 and <15)Pediatric Population <2
Abdominal Pain (particularly post prandial)AlopeciaAbdominal DistensionFailure to Thrive
Bloating/GasAmenorrheaPersonality Disorders
DiarrheaAphthous Ulcers/StomatitisShort Stature
Dermatitis HerpetiformisAsymptomaticThin Extremities
Down’s and Turner’s SyndromeAtaxia
Edema (hypoproteinemia)Cognitive Impairment
Iron Deficiency / AnemiaDelayed Onset of Puberty / Delayed Menarche
Severe Itchy RashDental Defects / Enamel Defects
Fertility Problems (male and female)
Heartburn / GERD
Lactose Intolerance
LFT Elevations
Nutritional Deficiencies (B12, Folate, Zinc, Vitamins A, D, E, K, etc.)
Peripheral Neuropathy
Pulmonary Hemosiderosis
Seizure Disorders
Thyroid Disorders
Refractory Vitamin D Deficiency
Urinary Stone Disease

Now look at an example of sIgA deficiency symptoms and imagine how this can present to a physician without experience in celiac disease diagnostics.[21][22]

Asthma of unknown cause
Chronic diarrhea
Gastrointestinal inflammation (Ulcerative colitis, Crohn’s disease can be causes)
Mouth infection
Otitis media
Skin infections
Upper respiratory tract infections

Incomplete or incorrect medical decision-making and my personal experience was the catalyst for my work in enhancing diagnostic knowledge and the understanding of the symptomatology, culminating in the creation, study and publication of a clinical decision-making expert system for celiac disease assessment.[23]

Regarding treatment being a life-long gluten free diet, data collected by researchers from the pharmaceutical company Takeda and the Celiac Disease Foundation reported 74% of individuals with celiac disease claimed they were exposed to gluten within the past 30 days.[24] If you really think about it that is not a shocking piece of information when gluten is omnipresent and cross contamination risk is so high. In 2010, Thompson and colleagues had twenty-two gluten free grains and seeds sent to a lab for gluten analysis.[25] Seven of the products were contaminated with gluten.[25] These products were considered gluten free by default because they are naturally gluten free and therefore were not labeled gluten free. Products studied included millet flour, millet grain, buckwheat, soy, brown rice, amaranth and flaxseed.[25] These are gluten free foods by nature, but obviously gluten contamination occurred via processing.[25] Strict gluten free labeling and testing is required to assure a product is gluten free.[25][27]

Moreover, there are known current conditions and diseases that have been linked to celiac disease in multiple studies in peer-reviewed literature.[2][19] Any of these diseases below should alert a physician to test for celiac disease risk.

It can take a village for a proper diagnosis to transpire. Celiac disease encompasses many different diseases, leaving signs to alert practitioners to start the diagnostic process. The Canadian Dental Association released a clinical diagnosis guide for dentists based on the oral manifestations of celiac disease, which include chronic dental carries, weak enamel and aphthous stomatitis, in an effort to screen patients for further testing.[7] The American Journal of Clinical Dermatology published a guide for dermatologists to enhance the recognition of cutaneous manifestations of celiac disease, with dermatitis herpetiformis being the primary sign.[8] Turco and colleagues noted an increase in anxiety and depression in children with celiac disease and functional intestinal disorders.[28]

Due to the fact that celiac disease can present as a clinical chameleon, alter the microbiome, is implicated in other autoimmune diseases, and can present with signs and symptoms that will most likely be seen by many different specialists in health care, a focus on obtaining an accurate diagnosis is key. If all these specialists are up to date in their knowledge of the many ways celiac disease can present in clinical practice and linked together in a health care information system, and sharing data via an electronic health record, may create an environment for a more accurate and prompt diagnosis, and improved continuity of care.


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  2. Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA. ACG Clinical Guidelines: Diagnosis and Management of Celiac Disease. Am J Gastroenterol 2013; 108:656–676; doi:10.1038/ajg.2013.79.
  3. Carlo Catassi, Debby Kryszak, Bushra Bhatti, Craig Sturgeon, Kathy Helzlsouer, Sandra L. Clipp, Daniel Gelfond, Elaine Puppa, Anthony Sferruzza, Alessio Fasano. Natural history of celiac disease autoimmunity in a USA cohort followed since 1974. Annals of Medicine, 2010.
  4. Rubio-Tapia A, Ludvigsson JF, Brantner TL, Murray JA, Everhart JE. The prevalence of celiac disease in the United States. Am J Gastroenterol. 2012 Oct;107(10):1538-44; quiz 1537, 1545. doi: 10.1038/ajg.2012.219.
  5. Mäki M, Mustalahti K, Kokkonen J, Kulmala P, Haapalahti M, Karttunen T, Ilonen J, Laurila K, Dahlbom I, Hansson T, Höpfl P, Knip M. Prevalence of celiac disease among children in Finland. N Engl J Med 2003;348:2517–24.
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  7. Rashid M, Zarkadas M, Anca A, Limeback HJ. Oral manifestations of celiac disease: a clinical guide for dentists. Can Dent Assoc. 2011;77:b39.
  8. Collin P, Reunala T. Recognition and management of the cutaneous manifestations of celiac disease: a guide for dermatologists. Am J Clin Dermatol. 2003;4:13-20.
  9. Collin P, Salmi TT, Hervonen K, Kaukinen K, Reunala T. Dermatitis herpetiformis: a cutaneous manifestation of coeliac disease. Ann Med. 2016 Aug 8:1-25
  10. McCormick C., Sultan M, Charabaty A. Celiac disease awareness among health care providers: diagnosis and nutritional and metabolic deficiencies: results of an anonymous online survey. Poster presented at the 2014 annual meeting of the American College of Gastroenterology (abstract P180) October 17 - 22, 2014; Philadelphia, Pennsylvania.
  11. Zipser RD., Farid M, Baisch D, Patel B, Patel D. BRIEF REPORT: Physician Awareness of Celiac Disease A Need for Further Education. J Gen Intern Med 2005; 20:644–646. DOI: 10.1111/j.1525-1497.2005.0107.x
  12. Assiri AM, Saeed A, Saeed E, El-Mouzan MI, Alsarkhy AA, Al-Turaiki M, Al Mehaideb A, Rashid M, Ullah A. Assessment of knowledge of celiac disease among health care professionals. Saudi Med J. 2015 Jun;36(6):751-3. doi: 10.15537/smj.2015.6.11519.
  13. Rostom A, Murray J, Kagnoff M. American Gastroenterological Association (AGA) Institute Technical Review on the Diagnosis and Management of Celiac Disease. Gastroenterology. 2006;131(6):1981-2002. doi:10.1053/j.gastro.2006.10.004.
  14. New Test Algorithms For Celiac Disease - Mayo Medical Laboratories. Web site. https://www.mayocliniclabs.com/it-mmfiles/Celiac_Disease_Diagnostic_Testing_Algorithm.pdf Updated August 2016. Accessed August 14, 2019.
  15. Mills JR1, Murray JA. Contemporary celiac disease diagnosis: is a biopsy avoidable? Curr Opin Gastroenterol. 2016 Mar;32(2):80-5. doi: 10.1097/MOG.0000000000000245.
  16. Fasano A. Zonulin and Its Regulation of Intestinal Barrier Function: The Biological Door to Inflammation, Autoimmunity, and Cancer. Physiol Rev. 2011;91:151–175.
  17. Henri-Bhargava A, Melmed C, Glikstein R, Schipper HM. Neurologic impairment due to vitamin E and copper deficiencies in celiac disease. Neurol. 2008;71:860-861.
  18. Ciacci C, Spagnuolo G, Tortora R, Bucci C, Franzese D, Zingone F, Cirillo M. Urinary stone disease in adults with celiac disease: prevalence, incidence and urinary determinants. J Urol. 2008 Sep;180(3):974-9. doi: 10.1016/j.juro.2008.05.007.
  19. Bai JC, Ciacci C, Corazza GR, Fried M, Olano C, Rostami-Nejad M., Gonzalez A, Green P, Gutierrez-Achury J, Schultz M, Verdu E, Barada K, Gibson P, Koletzko S, Coton T, Mulder C, Makharia G, LeMair A. World Gastroenterology Organisation Global Guidelines. Celiac Disease. July 2016. Available from http://www.worldgastroenterology.org/guidelines/global-guidelines/celiac-disease/celiac-disease-english on August 14, 2019.
  20. Al-Bawardy B, Codipilly DC, Rubio-Tapia A, Bruining DH, Hansel SL, Murray JA. Celiac disease: a clinical review. Abdom Radiol. 2017;1-10. DOI: 10.1007/s00261-016-1034-y
  21. Buckley RH. Primary defects of antibody production. In: Kliegman RM, Stanton BF, St Geme JW, Schor NF, eds. Nelson Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier; 2016:chap 124.
  22. Cunningham-Rundles C. Primary immunodeficiency diseases. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 250.
  23. Pastore RL, Murray JA, Coffman FD, Mitrofanova A, Srinivasan S. Physician Review of a Celiac Disease Risk Estimation and Decision-Making Expert System. J Am Coll Nutr. 2019 May 7:1-7. doi: 10.1080/07315724.2019.1608477. [Epub ahead of print] PubMed PMID: 31063433.
  24. Drahos J, Ren K, Geller M, Wang S, Leffler D. Adherence to the gluten-free diet and celiac disease patient outcomes: real world evidences from an international patient registry, iCureCeliac. Takeda Pharmaceuticals USA, Inc., IL, USA; 2Celiac Disease Foundation, CA, USA; 3Beth Israel Deaconess Medical Center, MA, USA.
  25. Thompson T, Lee A, R. & Grace, T. Gluten Contamination of Grains, Seeds and Flours in the United States: A Pilot Study. J Am Diet Assoc. 2010;110:937-940.
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  28. Turco R, Boccia G, Miele E, Giannetti E, Buonavolontà R, Quitadamo P, Auricchio R, Staiano A. The association of celiac disease in childhood with functional gastrointestinal disorders: a prospective study in patients fulfilling Rome III criteria. Aliment Pharmacol Ther. 2011;26:1365-2036.