Increasing numbers of patients are labeled as having celiac disease based on serological testing or even clinical presentation alone. A beneficial response to a gluten-free diet does not indicate celiac disease as it is not unusual for patients with irritable bowel syndrome and other conditions to benefit from such a diet. Individuals who have been diagnosed as having celiac disease without initial biopsy specimens obtained while on a gluten-containing diet should undergo additional testing including HLA testing and gluten challenge to confirm the diagnosis (Table 6.5). The optimum length of the gluten challenge has not been defined, but the recent literature suggests that serological and histological changes can be found as early as after one to two weeks of a diet containing at least 10 g of gluten per day (equivalent to four slices of bread). Sensitivity varies, however, and some patients quickly become ill on smaller amounts of gluten, while others, particularly those who have been gluten free for a longer time, will require a longer challenge. Typically, biopsies are obtained once the patient develops positive serologic studies, but a clinical response such as diarrhea may also be the basis for scheduling endoscopy. Most experts would recommend that small bowel biopsies are obtained even if there are no clinical or serological responses to the gluten change after a defined period of time, usually by six months.
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