Can celiac disease develop in adulthood?

Celiac Disease Can Develop at Any Age, Including Adulthood

Yes, celiac disease can definitely develop in adulthood, as it can manifest for the first time at any age. 1 This is contrary to the previously held belief that celiac disease was predominantly a childhood disorder characterized by malabsorption syndrome.

Epidemiology and Onset

Celiac disease is an immune-mediated, multisystem disorder that affects genetically susceptible individuals who are exposed to gluten-containing grains. Key points about adult onset include:

• The condition can develop at any point in life, from childhood through elderly years 2
• There has been a substantial increase in the prevalence of celiac disease over the last 50 years 3
• Many patients remain undiagnosed, particularly adults with atypical presentations 3

Clinical Presentation in Adults vs. Children

Adult presentations of celiac disease differ significantly from childhood presentations:

Adult Presentations

• Most adults present with non-classic symptoms 2
• Less specific gastrointestinal symptoms that may mimic irritable bowel syndrome 4
• Extraintestinal manifestations are common, including:
  • Anemia (particularly iron deficiency)
  • Osteoporosis
  • Elevated liver enzymes (transaminitis)
  • Recurrent miscarriage
  • Infertility or delayed menarche 5
  • Isolated nutritional deficiencies (especially iron, calcium, and vitamin D) 4

Childhood Presentations

• More likely to present with classic malabsorption syndrome
• Failure to thrive
• Diarrhea and weight loss
• More obvious gastrointestinal symptoms 6

Diagnostic Considerations

The diagnosis of celiac disease is based on a combination of clinical, serological, and histopathological data:

1. Initial screening: Immunoglobulin A tissue transglutaminase (IgA-TTG) with total IgA measurement 2

2. Confirmatory testing: Esophagogastroduodenoscopy with small bowel biopsy is recommended for most patients 2

   • In adults, biopsy is generally required for diagnosis
   • In children, biopsy may be avoided in specific circumstances with very high antibody levels

3. Genetic testing: HLA-DQ2 and HLA-DQ8 testing may be performed in select cases 2

Important Considerations for Adult-Onset Celiac Disease

• Diagnosis is often delayed in adults due to atypical presentations
• In a study of adult celiac patients, the median duration of symptoms before diagnosis was 2.5 years, with some patients experiencing symptoms for up to 40 years 5
• Only 44% of adult patients presented with chronic diarrhea, while 49% were referred by specialists for evaluation of conditions like refractory anemia, short stature, metabolic bone disease, or reproductive issues 5

Treatment

The primary treatment for celiac disease is a strict gluten-free diet for life, regardless of age at diagnosis 2. However, management differs substantially depending on the age at diagnosis 6.

Pitfalls to Avoid

1. Diagnostic delay: Don't dismiss the possibility of celiac disease in adults with vague symptoms or extraintestinal manifestations
2. Incomplete testing: Always perform testing while the patient is on a gluten-containing diet
3. Overlooking non-responsive cases: Patients who don't respond to a gluten-free diet should have their diagnosis confirmed, diet reassessed, and be evaluated for coexisting conditions 2

Celiac disease in adults is often a diagnostic challenge due to its protean manifestations. Maintaining a high index of suspicion is crucial for diagnosing variant forms of celiac disease in adults 5.