Celiac Disease Blood Work

aklap · Dec 22, 2010

Celiac Disease Blood Work

Doctors will usually start with a set of blood tests called a Celiac Panel that should consist of the tests below. If the panel does not include all tests, you may not get the entire picture. Be aware: Most doctors will run the tTG tests.

Please request your doctor to run ALL of these tests. Not all Doctors will know about Celiac Disease (CD) and may be unfamiliar with proper testing. This is where educating yourself becomes important.

You must be consuming gluten in order for these tests to be as accurate as they can be. Do not go gluten free (GF) before these tests are done.

If the blood tests come back positive, they may want to scope you to check for intestinal damage (the gold standard for Celiac diagnosis).

A Complete Celiac Blood Panel:

Antigliadin IgA and IgG*

May indicate Non Celiac Gluten Sensitivity. More info on NCGS

Most doctors exclude these tests, however, Dr. Alessio Fasano, Director of Univ. of Maryland Center for Celiac Research includes them in his blood work panel.

Dr. Fasano also reports that 60-70% of his patients that come to him thinking they have celiac disease, in reality he says they have Non-Celiac Gluten Sensitivity. The Antigliadin test is the best way to check for Non-Celiac Gluten Sensitivity.

See more info on Non Celiac Gluten Sensitivity Testing in the Explanation of Blood Test Section below. Pay close attention to Dr Ford & Dr. Peterson's sections.

*The Antigliadin IgA and IgG tests have fallen out of favor due to the lack of specificity [other medical issues can be the cause of these antibodies]. However, some organizations and Doctors do feel these tests are of importance and still include them in their panel of tests. Gluten maybe an issue, and should be investigated a bit further. These tests ARE included in followup testing to determine dietary compliance, so there is value to them.

Deamidated Gliadin Peptide IgG & IgA (DGP-IgG and DGP-IgA)

The DGP test is the new kid on the block and will likely over take tTG as the "test of choice" to detect intestinal damage (celiac disease). It's more specific and more sensitive.

As if celiac testing isn't confusing enough, this new test is being called the "Gliadin Test". This is confusing due to the older (now disappearing) Anti-Gliadin Autobody test listed above. The AGA & DGP tests look for two completely different things (see the explanation section below). Another problem is that labs are replacing the AGA tests for the DGP tests.

[*]Anti-tissue Transglutaminase Antibody (tTG) IgA
Anti-endomysial (EMA)

An indicator of villi damage [slight damage is not always detected. See More Info Section below].
These tests are highly specific to CD.
However, autoimmune diseases can skew the results of these tests

University of Chicago CD Center said:

It is important to note that some people with Type 1 Diabetes, Hashimoto?s thyroiditis and autoimmune liver conditions can have a falsely positive tissue transglutaminase test. For this reason, it is important that tTG test results in people with these conditions be checked with the EMA test. The physician may nevertheless want to obtain an intestinal biopsy if clinically indicated, even if EMA are negative.
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http://www.celiacdiseasecenter.columbia.edu/C_Doctors/C05-Testing.htm

Causes of false positive celiac serologic tests

The endomysial antibody test is virtually 100% specific for celiac disease. However anti-tTG has been reported to be positive in the presence of liver disease, especially cirrhosis [33], diabetes [34, 35] and severe heart failure [36], as well as arthritis [37] and various autoimmune disorders [38]. The use of human tTG as the antigen in the test kit adds some greater specificity. Antigliadin antibodies may be present in inflammatory bowel disease [39], collagen vascular disease [40], and in many healthy people as well [41].
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[*]Total serum IgA

Rules out IgA deficiency. If someone is not producing the IgA antibodies, it will skew the results of any IgA test. This must be run to ensure proper IgA test results

[*]Anti-reticulin IgA

Rarely used but, a very thorough doctor will include this

Prometheus Lab's Serology Product List - Note, recently this lab has switched out the Anti-Gliadin Autobody tests for the Deamidated Gliadin Peptide Tests

aklap · Dec 22, 2010

Explanation of Blood Tests

American Celiac Disease Alliance - Diagnosis

What are the different antibody tests available? Can there be errors in testing?

The blood tests can be divided into 2 different types of antibodies: those which are ?anti-gluten?, and those that ?anti-self?. The ?anti-gluten? antibodies are the anti-gliadin IgG and IgA. Ig stands for ?immunoglobulin? or ?antibody?. The ?anti-self? antibodies are anti-endomysial IgA and anti-tissue transglutaminase IgA.

***
Antigliadin antibodies

The antigliadin antibodies IgG and IgA recognize a small piece of the gluten protein called gliadin. These antibodies became available during the late 1970?s and were the first step towards recognizing CELIAC DISEASE as an autoimmune disorder. Antigliadin IgG has good sensitivity, while antigliadin IgA has good specificity, and therefore their combined use provided the first reliable screening test for CELIAC DISEASE.

Thanks to Cruelshoes/Colleen for suggesting this be broken out!
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http://glutendoctors.blogspot.com/

Dr. Petersen of HealthNow Medical explains the blood tests in her blog post titled "Interpreting Lab Work"

Dr Vikki Petersen said:

The data below comes from our book, The Gluten Effect ? available February 13, 2009.

Anti-tissue Transglutaminase Antibodies - Anti-tissue Transglutaminase Antibodies (tTG antibodies) are auto-antibodies directed against ?self? tissue. After gliadin crosses the intestinal lining, a special enzyme called tissue transglutaminase binds to gliadin and takes off a portion of the protein. This portion is called glutamine. tTG antibodies are antibodies that are directed against the complex of gliadin attached to the tissue transglutaminase enzyme. tTG antibodies are 90 percent accurate in Celiac disease because they represent immune system attack at the level of the intestinal lining. Gluten sensitivity that involves minor intestinal injury or no villous atrophy will be less likely detected by tTG antibodies. Therefore, tTG antibodies correlate best with villous atrophy as several studies have supported, and a negative tTG antibody test (or EM antibody test for that matter) does not rule out gluten sensitivity when intestinal involvement is minimal or absent.

Anti-Endomysial Antibodies - Anti-Endomysial Antibodies (EM antibodies) are auto-antibodies. Gliadin is a gluten protein so therefore when the immune system attacks it, is not attacking ?self? tissues but instead a foreign food protein. In contrast, as gliadin is absorbed through the intestinal lining, it attaches to the smooth muscle cells of the intestinal wall. EM antibodies are directed against proteins of these smooth muscle cells, and therefore EM antibodies are directed against ?self? tissue. This defines them as auto-antibodies.Because EM antibodies attack the smooth muscle of the small intestine, these antibodies correlate better with damage to the intestine wall. Studies have supported an accuracy rate of approximately 90 percent for Celiac disease. Actually in one study, EM antibodies were present in 100 percent of individuals when total villous atrophy was present. However, EM antibodies are ineffective in detecting individuals with silent or subclinical gluten sensitivity. If minor involvement of the intestinal lining occurs or if no intestinal involvement is present, EM antibodies are much less accurate.As with Anti-Gliadin Antibodies, EM antibody testing should evaluate IgG and IgA forms of antibodies. If a gluten sensitive patient is IgA deficient, IgA EM antibodies may be falsely negative even for Celiac disease.

Anti-Gliadin Antibodies - Gliadin is the protein component of gluten that triggers the immune reactions in sensitive people, and therefore many people with gluten sensitivity have antibodies to this protein. Testing for anti-gliadin antibodies (AGA) is a simple blood test, but studies have shown that it is less sensitive for detecting Celiac disease compared to other antibodies. The confusion is that the ability of AGA to detect gluten intolerance has been defined in conjunction with a positive intestinal biopsy. While this may be a standard for Celiac disease, we now know that this is an inaccurate standard for gluten sensitivity. In fact, AGA may be the best current diagnostic test when considering all gluten related disorders. In testing for AGA, antibodies of both the IgG and IgA classes are checked since low total levels of IgA may be present. If a person has low total IgA levels, antibody tests for IgA may be falsely negative.

Total Serum IgA Level - Low total levels of IgA antibodies are rarely found in the normal population with one out of every six hundred people having this condition, but in gluten sensitivity, low IgA levels are more common. This reflects the increased IgA antibody production in the intestine to fight off gluten as it attempts to enter our bodies. If a low level of IgA is present, then certainly IgG varieties of the antibody tests described above will be more accurate in diagnosing gluten related conditions. In general, total IgA levels are not ordered often since IgG antibody tests are usually ordered concurrently. Therefore, defining a low IgA level adds little information in making a diagnosis. There is a general theory however that a lower IgA level suggests greater inflammation of the intestinal lining and greater chronicity of disease. A low IgA level may provide some insight into duration of disease.

A high serum IgA level as seen in the above test is likely indicating an infection. Increased serum IgA is common in skin, gut, respiratory and renal infections. We know this patient has DH so secondary skin infections do make sense.
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*The Antigliadin IgA and IgG tests have fallen out of favor due to the lack of specificity [other medical issues can be the cause of these antibodies]. However, some organizations and Doctors do feel these tests are of importance and still include them in their panel of tests. Gluten maybe an issue, and should be investigated a bit further. These tests ARE included in followup testing to determine dietary compliance, so there is value to them.

aklap · Dec 22, 2010

Explanation of Blood Tests Continued

Dr. Rodney Ford - Recommended blood tests for Gluten problems

Dr Rodney Ford said:

TISSUE DAMAGE TESTS: TO LOOK FOR CELIAC DISEASE

Step one is to look for evidence of gut damage: this is to make a diagnosis of celiac (coeliac) disease. These "tissue damage" tests are called:

DGP-IgG (Diamidated Gliadin Peptide ? IgG)
tTG (tissue TransGlutaminase) - IgA
DPG-IgA (Diamidated Gliadin Peptide ? IgA)
EMA (Endomesial Antibodies) - IgA

Celiac disease is defined as the gut damage caused by gluten. When this happens, there is an over-reaction of the immune system in the gut. A harmful immune reaction is generated in the gut mucosa. This tissue injury involves inflammatory cells and the production of antibodies. These "tissue damage" tests can pick this up.

Studies demonstrate that where levels of these antibodies are elevated, more than 95% of patients will be found to have coeliac disease. Not surprisingly, there are now claims that a high DGP or tTG level is all that is required to make a diagnosis of celiac disease.
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TO LOOK FOR GLUTEN-SENSITIVITY

Step two is to look for evidence of gluten harm: this is to make the diagnosis of gluten-sensitivity (reactions to gluten without the gut damage).

Anti gliadin antibody ? IgG
Anti gliadin antibody ? IgA

A positive test shows that you have an immune reaction to gluten. This might not be causing symptoms yet. Most gluten-sensitive people have a high IgG-gliadin test.

The conflict of the IgG-gliadin test

There is disagreement surrounding the interpretation of the gliadin antibody test. It is found in elevated levels in about 10% of the population.

To summarise, beginning in the 1990s, the anti-gliadin IgG antibody test (often referred to as the IgG-gliadin test) was used to verify suspicion of celiac disease. However, it is a poor predictor of celiac disease. By contrast, the "tissue damage" antibodies (see above) are set off by bowel tissue damage and are excellent predictors of celiac disease.

There are two opposing schools of thought. First, the medical establishment, represented by the gastroenterologists, has concluded that the gluten blood tests are inaccurate and misleading (in relation to celiac disease). Their total focus is on the gut damage: and justify their position with the fact that gluten (gliadin) blood tests are poor predictors of who has the tissue damage caused by celiac disease.

This is true, but they then go on to make a serious error of logic. They say that because the gluten tests are not useful in detecting celiac disease, consequently, these gluten tests are not good for anything, and should be abandoned.

The IgG-gliadin test is a gluten test

Research shows that the IgG-gliadin antibody test is valuable for detecting people who are reacting adversely to gluten (but who do not have celiac disease).

The relationship between patient complaints and high levels of gluten antibodies has been widely investigated. Dr Ford's research has shown that high levels of gluten antibodies accurately predict a beneficial response to a gluten-free diet.

High IgG-gliadin antibody levels are indicative of an immunological reaction to gluten, which can manifest as significant poor health ? The Gluten Syndrome.
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Dr. Rodney Ford's Gluten-Free Planet Blog Post: Gluten blood tests - IgG-gliadin

Dr. Ford said:

What does the IgG-gliadin test measure?

The IgG-gliadin test measures your immune response to gliadin. Gliadin is part of the gluten molecule.
The IgG-gliadin test measures the levels of ANTIBODY to gluten (also called: IgG-anti gliadin antibody). This test doe not actually measure gluten. It measures your body?s REACTION against gluten.

Why does your body make this gliadin antibody?

Gliadin is a short protein that your body finds hard to breakdown in your gut. It is part of the gluten molecule. Because gliadin stays fairly much intact in the bowel, it is easy for it to get through the bowel mucosa in one piece and start to stimulate the cells of the immune system. These irritated immune cells start to make antibody molecules against gluten.

Do you have to be eating gluten at the time of the blood test?

No. The IgG-gliadin antibody test does not detect gluten. It is not a gluten test, rather it is a gluten reactivity test. Therefore, you do not have to eating gluten at the time of the blood tests. But the longer that you are on a gluten-free diet, the less accurate the IgG-gliadin tests will be.

I recommend having all of your blood tests before you go gluten free.

It takes between 6-18 months for your IgG-gliadin antibody levels to go down. So, as long as you have not been off gluten for more than 6 months, you can just go ahead and have the blood test.

If you have been off gluten for several years, it may take 2-4 months of eating gluten again before your gluten antibodies go high again.
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*The Antigliadin IgA and IgG tests have fallen out of favor due to the lack of specificity [other medical issues can be the cause of these antibodies]. However, some organizations and Doctors do feel these tests are of importance and still include them in their panel of tests. Gluten maybe an issue, and should be investigated a bit further. These tests ARE included in followup testing to determine dietary compliance, so there is value to them.
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aklap · Dec 22, 2010

Additional Testing

Due to the nature of Celiac Disease, it very common to find nutritional deficiencies. It's important to know this information as well.

Dr. Peter Green [world renowned CD expert] suggests this:

http://www.enabling.org/ia/celiac/medcare.html

Basic blood work is also included in the initial assessment. Such things as anemia and liver function need to be looked for. But it's very important to go further than that, and knowledge of the physiology of the small intestine should lead a physician to measure those nutrients that could be malabsorbed. Celiac Disease involves the small intestine, where iron, folic acid, calcium, fat soluble vitamins (Vitamins K, A, D, and E) and zinc are absorbed. These nutrients should be measured in the initial assessment and also during the course of the illness. Physicians will see patients who present with malabsorption of just one of these nutrients. If they are aware of the consequences of all these nutrient deficiencies, it will help them consider Celiac Disease as a possible diagnosis.
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Initial Assessment and Follow-up Care of Celiac Patients, by Peter Green, MD, summarized by Sue Goldstein

Even though it's not in this list - B12 should be checked as well.

More info on Diagnostic Testing:

Diagnostic Testing can be found in the The Gluten File

Clan Thompson's Testing and their Results. This is a really great resource. Please, spend some time looking this over.

Prometheus Labs CeliaPlus. Prometheus Labs is a respected and well known lab for processing Celiac Blood Panels. Note: You will be asked if you are medical professional. Of course you are!

Gluten Intolerance Group - Celiac Disease

Celiac Disease Center at Columbia University

Seronegative celiac disease

Both the anti-tTG and the EMA titers correlate with the severity of villous atrophy [26-29]. As a result in the presence of partial villous atrophy either antibody may be negative. In addition the mode of presentation of the celiac disease, i.e. presence of silent or subclinical celiac disease may be associated with a negative EMA [30]. Clinically seronegative celiac disease is similar to sero-positive celiac disease [23, 28] In view of the possibility of the presence of celiac disease in the absence of a positive anti-tTG or endomysial antibody the presence of a positive IgA AGA should prompt a biopsy [13]. Several studies have demonstrated that reliance on either anti-tTG or endomysial antibody as a single test will underestimate the prevalence of celiac disease [23, 25, 31, 32].

Positive serologic tests in the presence of a normal biopsy

This situation occasionally arises. The presence of a positive EMA with a normal biopsy indicates either the presence of celiac disease that was not detected in the biopsy, either because of too few pieces being taken or misinterpretation. The biopsy should be reviewed by an expert gastrointestinal pathologist. If it is considered to be truly a normal biopsy the patient may well have latent celiac disease and will probably develop the disease at a later date.
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Thanks to Cruelshoes/Colleen for suggesting this be broken out!
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False Negative Serological Results Increase with Less Severe Villous Atrophy

Celiac.com 08/27/2004 ? Dr. Peter Green and colleagues at the Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, conducted a study designed to determine the sensitivity of the various serological tests used to diagnose celiac disease. To do this they looked at 115 adults with biopsy-proven celiac disease who fulfilled strict criteria which included serological testing at the time of their diagnosis, and a positive response to a gluten-free diet. Out of those studied, 71% had total villous atrophy, and 29% had partial villous atrophy. Serological results indicated that only 77% of those with total and 33% of those with partial villous atrophy actually tested positive for celiac disease, and it did not matter whether the patients presented with classical or silent symptoms. All patients who were positive for anti-tissue transglutaminase had total villous atrophy. The researchers conclude:
Seronegative celiac disease occurs. Endomysial antibody positivity correlates with more severe villous atrophy and not mode of presentation of celiac disease. Serologic tests, in clinical practice, lack the sensitivity reported in the literature.
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Testing in children:

http://www.ncbi.nlm.nih.gov/pubmed/18852634?dopt=AbstractPlus

OBJECTIVES: The aim was to investigate age-dependent serum levels and occurrence of elevated celiac disease (CD)-related antibodies in young children, to define the optimal serological procedure when selecting for small intestinal biopsy. PATIENTS AND METHODS: Included were 428 children with biopsy verified CD (median age 16 months; range 7.5 months-14 years) and 216 controls (median age 2.7 years; range 8.5 months-14.6 years). Immunoglobulin (Ig) A antibodies against gliadin (AGA-IgA), tissue transglutaminase (tTG-IgA), and endomysium (EMA-IgA) were analysed. RESULTS: Increased serum AGA-IgA levels were found in 411 of 428 CD cases, tTG-IgA in 385 of 428, and EMA-IgA in 383 of 428. In the control group, 11 of 216 had increased levels of AGA-IgA, 5 of 216 of tTG-IgA, and 8 of 216 of EMA-IgA. In CD children younger than 18 months, elevated AGA-IgA occurred in 97% and elevated tTG-IgA and EMA-IgA were found in 83% of the cases. Conversely, in CD children older than 18 months, elevated AGA-IgA occurred in 94%, and elevated tTG-IgA and EMA-IgA were found in 99% of the cases.

CONCLUSIONS: In children older than 18 months, both tTG-IgA and EMA-IgA are sufficiently accurate to be used as a single antibody marker, whereas a large proportion of younger children with CD lack these antibodies. Therefore, when selecting children for small intestinal biopsy, the detection of a combination of AGA-IgA and tTG-IgA is optimal for identifying untreated CD in children younger than 18 months.
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aklap · Apr 13, 2010

Bump for Jaque

aklap · Jul 1, 2010

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khannen · Jul 2, 2010

I've read through this but am too tired to have any of it make much sense. Lol
Shealyn was just tested again with annual bloodwork that includes celiac testing apparently.

These good results? Any reason to look further?

TISSUE TRANSGLUTAMINASE IgA 6
IMMUNOGLOBULIN A 68 mg/dL

aklap · Aug 20, 2010

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aklap · Jan 14, 2011

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aklap · Mar 12, 2011

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aklap · Apr 18, 2011

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aklap · Jun 25, 2012

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