Stop the Villi-ous Cycle: The New Celiac Reality

Gluten-free: it’s everywhere! But just because you see it on nearly every restaurant menu and grocery store aisle, celiac disease is still underdiagnosed. 

In a 2025 CMAJ article, Celiac disease was highlighted as the most common autoimmune gastrointestinal disorder worldwide.

• Global seroprevalence: 1%–2%

• Canadian incidence rising: 6% annually

• Classic GI symptoms: only 30%

Pop quiz: Which specific HLA haplotypes are carried by 99% of patients with a Celiac diagnosis?

The "classic" presentation of diarrhea and weight loss is becoming the outlier. Most of our adult patients present with a normal Body Mass Index (or even elevated). We are often looking for the "silent" signs like iron-deficiency anemia, unexplained liver enzyme elevations, or even early menopause and infertility.

Diagnosis:

• Screening: The first-line test is tissue Transglutaminase Immunoglobulin A (just write TTG on a requisition)

• The Gluten Rule: Patients must eat roughly two slices of wheat bread daily for six weeks before testing.

• The IgA Catch: Always check total Immunoglobulin A levels to avoid false negatives from selective deficiency. (Some assays include this automatically)

• Gold Standard: Most Canadian adults still require an upper endoscopy with duodenal biopsies for a formal diagnosis.

  
  

Management:

• Gluten-Free Diet: This is a lifelong, strict removal of anything with gluten: including wheat, rye, and barley.

• Oat Safety: Pure, uncontaminated oats are generally safe, but avoid them if they aren't labeled "Gluten-Free."

• Referral: Every patient needs a Registered Dietitian to navigate cross-contamination and the 400% higher cost of "safe" foods.

• Vaccination: Consider Pneumococcal vaccines, as these patients have an increased risk of pneumonia.

EXAM TIP: On a SAMP, never pick "Gluten-Free Diet" as the first step for a patient with positive serology but no biopsy yet. The College wants you to prove the diagnosis with a referral for biopsy before committing a patient to a restrictive, expensive, lifelong treatment.

Also - TTG is ok for the 2026 Hybrid SAMP…abbreviations are OK according to the official CCFP Exam instructions to the candidate - as long as they're commonly used abbreviations that would be known to an examiner. You can find all of the exam documentation at our Exam Essentials page.

Source

Photo by Samir, CC BY-SA 3.0