Clinical and Immunological Features of Celiac Disease in Patients With Type 1 Diabetes Mellitus

Umberto Volta; Francesco Tovoli; Giacomo Caio


Expert Rev Gastroenterol Hepatol. 2011;5(4):479-487. 

In This Article

Clinical Presentation of CD in T1DM

Based on literature reports, CD observed in T1DM is classified as silent in approximately half of cases owing to the lack of symptoms suggestive for gluten-sensitive enteropathy.[7] However, CD patients are often labeled as asymptomatic when they are not and an accurate assessment of the clinical history allows the identification of more than one factor raising the suspicion of CD. Therefore, only one-quarter of CD cases associated with T1DM are totally asymptomatic.[22] Symptomatic CD in T1DM is characterized by extraintestinal and gastrointestinal symptoms with a slight prevalence of the former, but there are also patients with only gastrointestinal symptoms.[7,8,25,26] Among extraintestinal manifestations, the most frequent clues are short stature and iron-deficiency anemia (more rarely folic acid deficiency anemia), which are present in approximately 50% of cases.[22] Other rarer systemic signs suggesting CD in T1DM patients are a reduced BMI, diminished mass bone (osteopenia), bleeding due to vitamin K deficiency, delayed puberty, raised levels of transaminases and hypoglycemic episodes.[8,26] Hypoglycemia is thought to be caused by the altered absorption of nutrients at the intestinal level due to the unrecognized and untreated CD.[27] Among gastrointestinal symptoms, diarrhea and abdominal pain are the most frequently found, being present in 28 and 14% of cases, respectively.[22] However, abdominal distension, constipation and vomiting are also sometimes observed.[7,8,25,26] CD symptoms (both intestinal and extraintestinal) are much more frequent in children than in adolescents and adults.[16,28] In recent years, following the screening policy for CD in T1DM, a high number of subjects with positive CD-related antibodies but without diagnostic small bowel histology are being identified. These patients are classified as potential CD and they represent more than 12% of T1DM patients with a gluten-related immune disorder. Most of them are symptomless and only a minority (16%) display failure to thrive or gastrointestinal symptoms.[29]

In the majority of cases (more than 90%), the diagnosis of T1DM precedes that of CD.[7] In the few cases where CD is the first diagnosis, T1DM is diagnosed usually within the first months or 1 year from CD identification. In contrast to the majority of researchers and confirming the wide clinical spectrum of such an association, Valerio et al. reported that T1DM onset can frequently occur in patients with an already diagnosed CD (up to 25% of cases).[30] Controversial data have also been presented on the occurrence of autoantibodies predicting T1DM in previously diagnosed CD patients, which keeps the question open as to whether screening for islet cell and glutamate decarboxylase autoantibodies should be performed in this subset of patients.[11,31]


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