Celiac Disease and Irritable Bowel Syndrome
An Interview with Stuart Triester MD –
Scottsdale Healthcare Thompson Peak Gastroenterology
Dr. Purcell – Dr. Triester, thank you for taking the time out of your Friday afternoon schedule to meet with me.
Dr. Triester – Of course, it’s my pleasure.
Dr. Purcell – In the last few months, your name was mentioned by two personal friends of mine. Both of them had been to numerous Gastroenterologists before coming to see you. They both said that in addition to having excellent bedside manner that you were the most thorough GI doctor they had ever encountered. This was exciting for me to hear and I thought that members of the celiac disease support groups here in the valley might be able to benefit from your knowledge.
If you don’t mind, I have a few questions for you. There have been a number of health related questions that have come up at our monthly meetings I was hoping that you could shed some light on them.
Dr. Triester – Well, I’ll do my best to answer them.
Dr. Purcell – It seems like celiac disease sufferers are finally getting some respect. Gluten is in the news these days…
Dr. Triester – Yes it is, however celiac sufferers have found themselves caught in the “gluten-free wave” and the severity of the condition is still being overlooked. I will not ever recommend a gluten-challenge to a patient once they have stopped eating gluten so it is important to test for Celiac right away to either make the Diagnosis or rule it out.
Dr. Purcell – Right that’s one of the main points, in order for testing to be accurate a person must be eating gluten at the time of the test.
Dr. Triester – My threshold in testing for Celiac is very low. You can ask my staff how frequently we do celiac testing. I will test nearly every patient for Celiac in the initial workup unless it is obvious that is not his or her problem.
Dr. Purcell – What happens if a person has stopped eating gluten? Gluten is getting a bad reputation with books like Wheat Belly, and Grain Brain. Many people are going on a gluten-free diet.
Dr. Triester - If a patient has stopped eating gluten the only testing that is possible is genetic testing. If genetic testing is negative then I know that person does not have celiac disease. If genetic testing is positive it really has no value because 60% of all people tested will test positive.
Dr. Purcell – Is genetic testing covered by insurance?
Dr. Triester – Mostly, there are some exceptions.
Dr. Purcell – What laboratory are you using for genetic testing?
Dr. Triester – Prometheus Laboratory in San Diego, CA
Dr. Purcell – Are you finding that more people are being diagnosed at 40 years or older?
Dr. Triester – As opposed to younger people? Yes I diagnose quite a few people over forty.
Dr. Purcell – So what do you feel is happening with these people? Have they been suffering unknowingly their whole lives or are they developing Celiac later in life?
Dr. Triester – I’m certainly encountering people who could eat gluten at some point and then for whatever reason they are now Celiac positive. There are a number of theories out there as to how autoimmune diseases develop. The theory I like best is the molecular mimicry theory. Basically that we take a genetically susceptible individual and a trigger. The trigger could be an infectious bug that gets into the body and as the immune system starts to fight it the chemical structure looks a lot like the chemical structure of our own cells. The immune system becomes confused and begins to attack self.
Dr. Purcell – Right, Infections, stress, toxins come into the body of someone who is already genetically susceptible and flip a switch and then the immune system in an attempt to fight off the invaders attacks itself in the process. Do you find it necessary to re-test Antibodies once a patient has been diagnosed?
Dr. Triester – Yes, all patients get re-tested six months after diagnosis. I will re-test tTG-IgA. If a patient is following a gluten-free diet the antibodies will come down. If the antibodies do not come down then there are compliance or contamination issues with the diet.
Dr. Purcell – There are many celiac patients who avoid gluten yet continue to have Irritable Bowel symptoms, specifically diarrhea. Do you recommend additional follow-up care of these patients?
Dr. Triester – If a celiac patient avoids gluten and is still symptomatic there is a whole algorithm that I follow to determine if there is something else going on. Unfortunately many of these patients then get labeled as IBS (irritable bowel syndrome) and no further work-up is done.
Dr. Purcell – Right, it seems that many patients Celiac or otherwise get lumped into the diagnosis of IBS and then are given the brush off. It is rare for a doctor to question the diagnosis of IBS and look for something more. These are the types of patients that I see with a miserable quality of life who are looking for answers using a Naturopathic approach.
Dr. Triester – Once a Celiac patient is properly diagnosed and improving then follow-up care is just like any other patient. Routine colonoscopies every 5-10 years depending on the person’s history. With nutritional replacement I am less knowledgeable. Absorption will improve over time with the avoidance of gluten so it’s hard for me to know how much vitamin or mineral replacement I should recommend to a patient because it will change.
Dr. Purcell – That’s correct, testing for nutritional status is as important as re-testing the tTg antibodies. Nutritional needs will change as digestion improves and it is important for patients to have a Naturopathic Doctor on their team to monitor that as well as help support digestive function. Do you have any advice for a newly diagnosed celiac patient?
Dr. Triester – Be Patient. It is very difficult to go gluten-free in a week. There are items you never even thought about that will contain gluten. You will make mistakes and that’s ok. Symptoms will resolve over time. Sometimes I have to remind myself to be patient when I am working with my patients. Each person’s body will heal at a different rate. Some symptoms will take longer than others to resolve.
Dr. Purcell – Dr. Triester, It was truly a pleasure conversing with you this afternoon. I can tell that you are a passionate and caring doctor.
The Phoenix chapter of the Celiac Disease Foundation has provided me with brochures to leave with you as a resource for your patients.
As an additional thank you I am gifting you with a copy of my gluten-free cookbook for your waiting room. Thank you for your time and have a great weekend.
Dr. Triester – Oh wow, this will be great for the waiting room. Thank you Dr. Purcell and you do the same.