Can celiac disease manifest at age 27?

Can Celiac Disease Manifest at Age 27?

Yes, celiac disease absolutely can and does manifest at age 27—in fact, the majority of celiac disease cases are diagnosed in adulthood, with most remaining undiagnosed until later in life. 1, 2

Age of Onset and Diagnosis

Celiac disease can develop at any age, and clinicians should maintain heightened suspicion across all age groups and both sexes. 1, 3 The evidence clearly demonstrates:

• Approximately 65-75% of celiac disease diagnoses occur after age 18, with the median age of diagnosis often extending well into adulthood 4
• About 25% of all diagnoses are made at age 60 or older, and approximately 20% at age 65 or over, with 4% diagnosed at age 80 or above 5
• The general population prevalence is approximately 1% (1:100), but the majority of cases remain undiagnosed until adulthood 1, 2

Why Adult-Onset Presentation Occurs

The pathophysiology involves a complex interplay where gluten sensitivity and autoimmunity can be triggered at any point in life. 1 While the exact mechanisms of disease initiation remain incompletely understood, it has been hypothesized that:

• Environmental triggers such as enteric infections or recent surgery may compromise epithelial barrier function and initiate intestinal inflammation 1
• Genetic susceptibility (HLA-DQ2/DQ8) is present from birth, but disease expression can be delayed for decades 6

Clinical Presentation at Age 27

Adult patients typically present with non-classical symptoms rather than the classic gastrointestinal complaints seen in children. 3, 4 At age 27, expect:

• Less specific gastrointestinal symptoms: chronic diarrhea (48.5%), abdominal pain, bloating 4
• Extraintestinal manifestations: unexplained iron-deficiency anemia (very common), osteoporosis, elevated transaminases (24.3% of patients), recurrent miscarriage 1, 3, 4
• Subtle presentations: tiredness, indigestion, reduced appetite 5
• Median symptom duration before diagnosis: 54 months (range 1 month to 29 years), indicating significant diagnostic delay 4

Critical Diagnostic Considerations

Over 40% of adult celiac patients present to clinicians other than gastroenterologists with atypical manifestations, requiring a high index of suspicion. 4 For a 27-year-old patient:

• Screen with tissue transglutaminase IgA (tTG-IgA) along with total IgA levels (sensitivity 90-97%, specificity 96-100%) 7
• All serologic testing must be performed before initiating a gluten-free diet, as gluten withdrawal causes false-negative results 7
• Confirm diagnosis with esophagogastroduodenoscopy and duodenal biopsy in adults, even with positive serology 3
• Document total IgA levels because IgA deficiency occurs in 1-3% of celiac patients and causes falsely negative tTG-IgA results 7

Common Pitfalls to Avoid

• Do not dismiss celiac disease based on age—the notion that it only presents in childhood is outdated 1, 2
• Do not overlook non-classical presentations—only about 24% of individuals with celiac disease are diagnosed, creating a "celiac iceberg" of undiagnosed cases 2
• Do not allow patients to start a gluten-free diet before completing diagnostic evaluation, as this makes subsequent testing unreliable 7, 6

Prognosis and Management

Over 90% of adult patients achieve good compliance with a gluten-free diet, with resolution of symptoms and improvement in laboratory indices. 5 The diagnosis at age 27 is actually advantageous because:

• Treatment response is excellent when diagnosed and managed appropriately 5
• Increased risks of mortality and comorbidity are generally observed in the first 1-2 years following diagnosis, emphasizing the importance of early detection 2
• Lifelong gluten-free diet remains the primary treatment, with patients benefiting from dietitian support and education 3