乳糜泻

应在诊断时将患者转诊给营养师，然后每年进行一次病情检查，以指导和监测他们依从无麸质饮食的情况。在开始无麸质饮食后，抗组织型转谷氨酰胺酶 IgA 抗体（immunoglobulin A-tissue transglutaminase, IgA-tTG）的正常化与黏膜愈合之间可能存在不一致性。[104]Silvester JA, Kurada S, Szwajcer A, et al. Tests for serum transglutaminase and endomysial antibodies do not detect most patients with celiac disease and persistent villous atrophy on gluten-free diets: a meta-analysis. Gastroenterology. 2017 Sep;153(3):689-701;e1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5738024/ http://www.ncbi.nlm.nih.gov/pubmed/28545781?tool=bestpractice.com 黏膜完全恢复的时间有所不同；不到半数的乳糜泻患者在坚持无麸质饮食 1 年后十二指肠组织学表现恢复正常，成人比儿童黏膜愈合的可能性更小。[137]Szakács Z, Mátrai P, Hegyi P, et al. Younger age at diagnosis predisposes to mucosal recovery in celiac disease on a gluten-free diet: a meta-analysis. PLoS One. 2017 Nov 2;12(11):e0187526. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5695627/ http://www.ncbi.nlm.nih.gov/pubmed/29095937?tool=bestpractice.com 症状并不能很好地预测黏膜炎症或恢复情况。[138]Mahadev S, Murray JA, Wu TT, et al. Factors associated with villus atrophy in symptomatic coeliac disease patients on a gluten-free diet. Aliment Pharmacol Ther. 2017 Apr;45(8):1084-93. https://onlinelibrary.wiley.com/doi/full/10.1111/apt.13988 http://www.ncbi.nlm.nih.gov/pubmed/28220520?tool=bestpractice.com

如果患者在坚持无麸质饮食 1 年后出现临床和血清学缓解，可考虑在接下来的 2 年内每年进行一次随访，此后每 2 年一次。[23]Al-Toma A, Volta U, Auricchio R, et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J. 2019 Jun;7(5):583-613. https://journals.sagepub.com/doi/10.1177/2050640619844125?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed& http://www.ncbi.nlm.nih.gov/pubmed/31210940?tool=bestpractice.com

应向患者开具口服补充剂处方，以治疗诊断时存在的任何营养缺乏症，并且应进行监测，直至这些缺乏恢复正常。

IgA-tTG 滴度通常在确诊后的第一年至少检查 3 次（3 个月、6 个月和 12 个月时），然后每年检查一次，作为饮食依从性的一个指征。[23]Al-Toma A, Volta U, Auricchio R, et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J. 2019 Jun;7(5):583-613. https://journals.sagepub.com/doi/10.1177/2050640619844125?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed& http://www.ncbi.nlm.nih.gov/pubmed/31210940?tool=bestpractice.com [105]Husby S, Bai JC. Follow-up of celiac disease. Gastroenterol Clin North Am. 2019 Mar;48(1):127-36. http://www.ncbi.nlm.nih.gov/pubmed/30711205?tool=bestpractice.com 在大多数患者中，IgA-tTG 的滴度应在 6 至 9 个月内恢复正常，[139]Mangione RA, Patel PN. Caring for patients with celiac disease: the role of the pharmacist. J Am Pharm Assoc (2003). 2008 Sep-Oct;48(5):e125-35. http://www.ncbi.nlm.nih.gov/pubmed/18826893?tool=bestpractice.com 但有些患者（例如，严重黏膜萎缩、1 型糖尿病、诊断时滴度极高的儿童）可能需要 3 年以上的时间。[140]Gidrewicz D, Trevenen CL, Lyon M, et al. Normalization time of celiac serology in children on a gluten-free diet. J Pediatr Gastroenterol Nutr. 2017 Mar;64(3):362-7.  http://www.ncbi.nlm.nih.gov/pubmed/28231071?tool=bestpractice.com [141]Isaac DM, Rajani S, Yaskina M, et al. Antitissue transglutaminase normalization postdiagnosis in children with celiac disease. J Pediatr Gastroenterol Nutr. 2017 Aug;65(2):195-9. http://www.ncbi.nlm.nih.gov/pubmed/27906802?tool=bestpractice.com 如果 IgA-tTG 滴度呈下降趋势，患者无症状，营养缺乏问题得到解决，则无需立即采取措施。

临床应答良好的患者以及 IgA-tTG 已恢复正常的患者无需常规重复进行内镜检查。

可在诊断时或坚持无麸质饮食 1 年后评估成人患者的骨密度。[23]Al-Toma A, Volta U, Auricchio R, et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J. 2019 Jun;7(5):583-613. https://journals.sagepub.com/doi/10.1177/2050640619844125?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed& http://www.ncbi.nlm.nih.gov/pubmed/31210940?tool=bestpractice.com [55]Rubio-Tapia A, Hill ID, Kelly CP, et al. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol. 2013 May;108(5):656-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3706994/ http://www.ncbi.nlm.nih.gov/pubmed/23609613?tool=bestpractice.com [132]Ludvigsson JF, Bai JC, Biagi F, et al. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut. 2014 Aug;63(8):1210-28. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4112432/ http://www.ncbi.nlm.nih.gov/pubmed/24917550?tool=bestpractice.com [133]Bai JC, Ciacci C. World Gastroenterology Organisation global guidelines: celiac disease February 2017. J Clin Gastroenterol. 2017 Oct;51(9):755-68. http://www.ncbi.nlm.nih.gov/pubmed/28877080?tool=bestpractice.com [142]West J, Logan RF, Card TR, et al. Fracture risk in people with celiac disease: a population-based cohort study. Gastroenterology. 2003 Aug;125(2):429-36. http://www.ncbi.nlm.nih.gov/pubmed/12891545?tool=bestpractice.com [143]Bai JC, Gonzalez D, Mautalen C, et al. Long-term effect of gluten restriction on bone mineral density of patients with coeliac disease. Aliment Pharmacol Ther. 1997 Feb;11(1):157-64. https://onlinelibrary.wiley.com/doi/epdf/10.1046/j.1365-2036.1997.112283000.x http://www.ncbi.nlm.nih.gov/pubmed/9042988?tool=bestpractice.com