Is Endoscopy Necessary?

[Olivia28]

I have had Type 1 Diabetes for 3 years and just got a call from my Dr. that I tested positive for Celiac Antibodies. I don't believe I've ever been tested for them before. I have no symptoms. This is what my lab work says:

Endomysial Antibody (IgA) Screen: POSITIVE
Transglutaminase IgA Antibodies 12 U/ml IgA 182 (81-463 standard range)
Endomysial Antibody Titer 1:20 (standard range <1:5)

I'm terrified of having an endoscopy. What is the advantage to having one? Either way I will likely be put on a gluten-free diet, right? Even if an endoscopy shows no damage, I likely still have Celiac (or will develop it), right? 

Thanks so much! I've been blindsided by this diagnosis and any help would be appreciated.

 

[Altoma]

Yes, you still need endoscopy and biopsy because you do not have symptoms and the level of antibodies is not clearly discriminative, it is borderline positive.

https://doi.org/10.1177/2050640619844125

https://www.ueg.eu/quality-of-care/guidelines/

 

Al-toma, consultant gastroenterologist 

[GFinDC]

Hi Olivia,

Welcome to the forum!

First off, don't be scared of the endoscopy.  When I had mine they did both endoscopy and a colonoscopy at the same time.  The GI called it a two-fer.  That was good because they found and removed some polyps.  I never would have known they were there otherwise.  I was out for the procedure so it was like falling asleep and waking back up seconds later and it was over.  I didn't even know it was done.  Since they are both invasive procedures it is not a bad idea to get them done in one hospital visit instead of two.  That saves time and money.

The endoscopy is considered the actual proof of celiac damage.  They check for evidence of an immune attack on the small intestine lining.  In theory the antibodies could be in the bloodstream but not attacking the small intestine.  So the endoscopy proves celiac damage from antibodies.

There are some other blood tests you could ask for first though.  There are tests called DGP IgA and DGP IgG that he can do. Also the total serum IgA is good to do so they know if your immune system actually makes normal amounts of IgA antibodies.  Without IgA production, the IgA tests are useless.  Some people just don't make IgA.  The results you got do seem to indicate you are making IgA antibodies though.

Another thing you could ask for is a test of your vitamin and mineral levels.  These are sometimes out of whack (low) in celiac patients because of intestinal damage.

You could get a gene test also but it doesn't prove celiac.  Around 30% of people in the USA have one of the celiac related genes but only 1% get celiac.

I am guessing you got the full celiac panel but didn't post all the results?

Anyhow, please don't go gluten-free yet as that would mess up any upcoming tests results.

[cyclinglady]

Welcome!

What was the lab range for the TTG IgA test (your result was 12)?  Your Immunoglobulin A (IgA) test is within range that means any other IgA related test should be valid.  The EMA is pretty specific to celiac disease.  

Consider getting that endoscopy.  They put me out and I had no issues at all!  Why get it?  Because it confirms celiac disease.  The blood tests help but are not perfect.  Plus, the endoscopy can assess the damage level which can come in handy later on (benchmark). Not to mention some Gi’s will not give a diagnosis without it.  

I have a firm diagnosis, but my hubby (who went gluten free some 20 years ago based on the advice of two medical doctors) does not.  He is doing well.  Refuses to do a challenge because he would have to consume gluten and he knows that it makes him sick.  But he will tell you that I get way more support from medical, family and friends.  It is easy to get our kid tested periodically (even if symptom free) because of my diagnosis.  I might even have some protection if I go to jail!  ?. 

My last endoscopy revealed a healthy, healed small intestine.  So different from my Marsh Stage IIIB five years ago.  Like you, I was pretty much symptom free.  My only symptom as anemia which was always blamed on another genetic anemia I have (Thalassemia).  You are lucky your endo or PCP tested you for celiac disease.    Sounds like a keeper!  

So, before you make a firm decision, take the time to research and think about it.  You have a very strong possibility of having celiac disease because TD1, autoimmune thyroiditis and celiac disease are strongly linked due to gene type.  A firm diagnosis might be important to you  later.  Some folks do not have the opportunity to even get a diagnosis for many reasons.  

Edited May 2, 2019 by cyclinglady

[Olivia28]

1 hour ago, GFinDC said:

Hi Olivia,

Welcome to the forum!

First off, don't be scared of the endoscopy.  When I had mine they did both endoscopy and a colonoscopy at the same time.  The GI called it a two-fer.  That was good because they found and removed some polyps.  I never would have known they were there otherwise.  I was out for the procedure so it was like falling asleep and waking back up seconds later and it was over.  I didn't even know it was done.  Since they are both invasive procedures it is not a bad idea to get them done in one hospital visit instead of two.  That saves time and money.

The endoscopy is considered the actual proof of celiac damage.  They check for evidence of an immune attack on the small intestine lining.  In theory the antibodies could be in the bloodstream but not attacking the small intestine.  So the endoscopy proves celiac damage from antibodies.

There are some other blood tests you could ask for first though.  There are tests called DGP IgA and DGP IgG that he can do. Also the total serum IgA is good to do so they know if your immune system actually makes normal amounts of IgA antibodies.  Without IgA production, the IgA tests are useless.  Some people just don't make IgA.  The results you got do seem to indicate you are making IgA antibodies though.

Another thing you could ask for is a test of your vitamin and mineral levels.  These are sometimes out of whack (low) in celiac patients because of intestinal damage.

You could get a gene test also but it doesn't prove celiac.  Around 30% of people in the USA have one of the celiac related genes but only 1% get celiac.

I am guessing you got the full celiac panel but didn't post all the results?

Anyhow, please don't go gluten-free yet as that would mess up any upcoming tests results.

Thank you so much for your response. Those blood test results are the only ones I received. It's frustrating that I have to keep eating gluten even though it's likely damaging my body, but I will take your advice. Thanks again!

[Olivia28]

1 hour ago, cyclinglady said:

Welcome!

What was the lab range for the TTG IgA test (your result was 12)?  Your Immunoglobulin A (IgA) test is within range that means any other IgA related test should be valid.  The EMA is pretty specific to celiac disease.  

Consider getting that endoscopy.  They put me out and I had no issues at all!  Why get it?  Because it confirms celiac disease.  The blood tests help but are not perfect.  Plus, the endoscopy can assess the damage level which can come in handy later on (benchmark). Not to mention some Gi’s will not give a diagnosis without it.  

I have a firm diagnosis, but my hubby (who went gluten free some 20 years ago based on the advice of two medical doctors) does not.  He is doing well.  Refuses to do a challenge because he would have to consume gluten and he knows that it makes him sick.  But he will tell you that I get way more support from medical, family and friends.  It is easy to get our kid tested periodically (even if symptom free) because of my diagnosis.  I might even have some protection if I go to jail!  ?. 

My last endoscopy revealed a healthy, healed small intestine.  So different from my Marsh Stage IIIB five years ago.  Like you, I was pretty much symptom free.  My only symptom as anemia which was always blamed on another genetic anemia I have (Thalassemia).  You are lucky your endo or PCP tested you for celiac disease.    Sounds like a keeper!  

So, before you make a firm decision, take the time to research and think about it.  You have a very strong possibility of having celiac disease because TD1, autoimmune thyroiditis and celiac disease are strongly linked due to gene type.  A firm diagnosis might be important to you  later.  Some folks do not have the opportunity to even get a diagnosis for many reasons.  

Thanks for your response! The lab test says <4 No Antibody Detected, >OR=4 Antibody Detected

It was my endocrinologist who ordered the test because of my Type 1 Diabetes...though again, this is so surprising because I don't have symptoms. I guess I'll try to be brave and get the endoscopy. I really appreciate the advice. 

[pikakegirl]

I think GFinDC has sound advice. I was IgA and CRP elevated and read about Celiac. I have silent Celiac and had lots of strange symptoms and it was missed for over a decade. The endoscopy was a breeze. No pain afterward, no overnight stay. Biopsy positive for damage and I only had 2 feet of undamaged Small intestine. It has been 13years of healing and GI looks totally healed but I still have leaky gut symptoms and food intolerances which are fading. 

A friend of mine did not get the biopsy and she skirts her mind around being  gluten intolerant one day and Celiac the next. She lives her life on the gluten consumption edge getting sick here and there. If she is Celiac it is damaging her. Wish her Dr. was more firm about the biopsy so she could be more serious about her health. 

[Olivia28]

4 hours ago, Altoma said:

Yes, you still need endoscopy and biopsy because you do not have symptoms and the level of antibodies is not clearly discriminative, it is borderline positive.

https://doi.org/10.1177/2050640619844125

https://www.ueg.eu/quality-of-care/guidelines/

 

Al-toma, consultant gastroenterologist 

Thanks so much for your reply! A Gastroenterologist won't see me for a few weeks and I've been trying to decipher these test results online. It's helpful to know they're borderline. 

[Olivia28]

4 hours ago, Altoma said:

Yes, you still need endoscopy and biopsy because you do not have symptoms and the level of antibodies is not clearly discriminative, it is borderline positive.

https://doi.org/10.1177/2050640619844125

https://www.ueg.eu/quality-of-care/guidelines/

 

Al-toma, consultant gastroenterologist 

Just out of curiosity, what would the recommendation be if my biopsy is negative? Because I have some antibodies, am I likely to develop Celiac? Should I follow a gluten-free diet anyway? 
Thanks again!

[cyclinglady]

Keep eating gluten until that GI consult.  In fact, you must be consuming gluten for even the intestinal biopsies.  

I can share that I test positive to ONLY the DGP IgA tests, even on follow-up testing using different labs, yet I had intestinal damage and no GI issues.  As time went on, my celiac disease changed.  I did get GI symptoms after gluten exposures.  Why just one odd positive on the celiac panel?  No one knows.  I can not find any literature (except this happens to toddlers and the elderly) nor do my two GIs have an answer.  I do have other autoimmune disorders (Hashimoto’s and Chronic Autoimmune Gastritis) and perhaps those impacted my antibodies tests.  

If your biopsies are negative?  No sense in planning for something that might never happen.  I know, it is hard to be patient!  Do know that in my personal, non-medical  opinion, not treating celiac disease can cause other autoimmune issues.  Like my kid, you might need to be tested every few years, but again, wait until that GI consult.  Know that about 10% of celiacs do not have any antibodies.  Make sure your GI is aware of that.  You do NOT need to have positives on all the celiac blood tests.  Just one is needed to move forward and you have that.  Plus, you already have a high risk factor — TD1.  

[cyclinglady]

22 hours ago, Altoma said:

Yes, you still need endoscopy and biopsy because you do not have symptoms and the level of antibodies is not clearly discriminative, it is borderline positive.

https://doi.org/10.1177/2050640619844125

https://www.ueg.eu/quality-of-care/guidelines/

 

Al-toma, consultant gastroenterologist 

Thanks for the updated links.  I bookmarked them.  It is nice to be able to see  the EU guidelines for celiac disease.  

[Ennis-TX]

I just had a double scope Wednesday to see how my intestines where doing. Worst part is the prep and the bill (>.> Still unsure how I am going to pay it out). Liquid diet the day before and the night before they had me do the doctors recommended clean out for this doctor it was 3 bottles of magnesium citrate, and 48oz of extra liquid. Last doc had me do liquid diet for 2 days then a dulcolax 2 tabs and 64 oz of liquid with a full bottle of miralax. Basically you flush out your intestines nice and clean for them to take pictures of, but will spend a evening in the bathroom and get plenty of reading done.

Day of the procedure no food, drinks, gum, etc. You go in get signed in, they have your put on the hospital gown and hook you up to a IV. Once they give you the anesthesia through the IV you go out, and come to what feels like just seconds later (Actually 30-60mins) feeling oddly well rested like someone hit a reset button. Few days of sore throat and residual gut issues, I found probiotics and easy to digest foods helped get me back up on track quickly.

I came back with complete healing of both my intestines from celiac and UC, but I have been gluten free for 6 years and following a paleo/keto diet for my UC for over a year now.

[cyclinglady]

32 minutes ago, Ennis_TX said:

I just had a double scope Wednesday to see how my intestines where doing. Worst part is the prep and the bill (>.> Still unsure how I am going to pay it out). Liquid diet the day before and the night before they had me do the doctors recommended clean out for this doctor it was 3 bottles of magnesium citrate, and 48oz of extra liquid. Last doc had me do liquid diet for 2 days then a dulcolax 2 tabs and 64 oz of liquid with a full bottle of miralax. Basically you flush out your intestines nice and clean for them to take pictures of, but will spend a evening in the bathroom and get plenty of reading done.

Day of the procedure no food, drinks, gum, etc. You go in get signed in, they have your put on the hospital gown and hook you up to a IV. Once they give you the anesthesia through the IV you go out, and come to what feels like just seconds later (Actually 30-60mins) feeling oddly well rested like someone hit a reset button. Few days of sore throat and residual gut issues, I found probiotics and easy to digest foods helped get me back up on track quickly.

I came back with complete healing of both my intestines from celiac and UC, but I have been gluten free for 6 years and following a paleo/keto diet for my UC for over a year now.

Congratulations!  It is so nice to know that you have been adhering to the gluten-free diet and your methods are working for you.   What is more amazing is how you have managed your UC without heavy duty prescription drugs.  That is incredible.   I wish you continued success.  You are an inspiration to me, members, and especially the newbies!  

 

Edited May 5, 2019 by cyclinglady

[Beverage]

My blood results were very high, so I went with that, positive on the DNA test, and the results from a gluten free diet to get an official medical diagnosis.  I agree with the others, though that in your case, the endoscopy is probably needed, although can get false negatives on it, as it's been talked about many times in here.  After that, you might end up with having to do the DNA test and just try the gluten free diet to see your response to it.

[Gemini]

On 5/2/2019 at 9:23 AM, Olivia28 said:

I have had Type 1 Diabetes for 3 years and just got a call from my Dr. that I tested positive for Celiac Antibodies. I don't believe I've ever been tested for them before. I have no symptoms. This is what my lab work says:

Endomysial Antibody (IgA) Screen: POSITIVE
Transglutaminase IgA Antibodies 12 U/ml IgA 182 (81-463 standard range)
Endomysial Antibody Titer 1:20 (standard range <1:5)

I'm terrified of having an endoscopy. What is the advantage to having one? Either way I will likely be put on a gluten-free diet, right? Even if an endoscopy shows no damage, I likely still have Celiac (or will develop it), right? 

Thanks so much! I've been blindsided by this diagnosis and any help would be appreciated.

 

Olivia....from someone who opted out of the biopsy, I'll give you some info that might help.  Not that I don't think you should have one but from what you posted above, having a positive tTg AND a positive EMA (Endomysial Antibody) is pretty much a slam dunk for Celiac Disease.  If you have this combination, it's about 99% positive for Celiac without the biopsy.  Not to mention you also have Type 1 diabetes, which is one of those AI diseases that likes to appear along with Celiac.  There is a genetic link between the two diseases.

So, nothing wrong with having the biopsy but with these results, you are about 99% certain to have it.  You also probably do have some symptoms but might not link them to Celiac.  That is common with us all.  At this point with the biopsy, it's more an issue of seeing how much damage you have vs. diagnosis.

Good luck to you!

[Posterboy]

On 5/2/2019 at 2:32 PM, Olivia28 said:

Thanks so much for your reply! A Gastroenterologist won't see me for a few weeks and I've been trying to decipher these test results online. It's helpful to know they're borderline.  

On 5/2/2019 at 2:47 PM, Olivia28 said:

Just out of curiosity, what would the recommendation be if my biopsy is negative? Because I have some antibodies, am I likely to develop Celiac? Should I follow a gluten-free diet anyway? 
Thanks again!

Olivia28,

I think they have all given you good advice... and we are all different. ..some had biopsy proven celiac and some of us was diagnosed by high blood serology alone (me).

I just wanted to follow up with a few links for you if you can't get into your GI for a few weeks to read so you will have some good questions for him.

I think they will  answer most of your questions.

https://www.the-rheumatologist.org/article/diagnostic-tests-tips-gluten-induced-celiac-disease/?singlepage=1

Don't forget (though not well understood (yet)) NCGS is an auto-immune condition too!

https://www.the-rheumatologist.org/article/non-celiac-wheat-sensitivity-immune-disorder/?singlepage=1

so while you might not be having GI problems (yet) don't be surprised if other "phantom" symptom's disappear once you go gluten free for good....I usually had fall/winter bronchitis etc. like clock work that is now gone.  I also had several ear ache/infections I now longer have any more as just a couple of examples.

You will look back in a year and be amazed how much better you feel overall!

If you truly are not having any GI problems (are a going once a day) then you might be having reactions to medicine(s) you could be taking...it is called  a false positive....see link about Diagnostic tests for gluten induced celiac disease that covers this phenomena.

I had this problem with my 'Sartan' type BP medicine.

See my experience here

I hope this is helpful but it is not medical advice.

Posterboy,

[notme]

( hi, gem!  ?  I was wondering whereyat! )

olivia, a solid diagnosis is like the holy grail of this disease.  if it takes a scope, do it.  it's not painful, at least it isn't for most.  my doc warned me I might have a sore throat afterwards, but I came home and ate a turkey sammich.  

getting a endoscopy will also hopefully rule out other conditions.

allll my bloodwork and labs came back negative, but I was already off gluten and my doc didn't want me to do a gluten challenge bc I was so underweight that when I went off gluten and immediately gained 20 lbs.  the doctor could see the damage celiac had done when I had the scope.  

[Olivia28]

7 hours ago, Gemini said:

Olivia....from someone who opted out of the biopsy, I'll give you some info that might help.  Not that I don't think you should have one but from what you posted above, having a positive tTg AND a positive EMA (Endomysial Antibody) is pretty much a slam dunk for Celiac Disease.  If you have this combination, it's about 99% positive for Celiac without the biopsy.  Not to mention you also have Type 1 diabetes, which is one of those AI diseases that likes to appear along with Celiac.  There is a genetic link between the two diseases.

So, nothing wrong with having the biopsy but with these results, you are about 99% certain to have it.  You also probably do have some symptoms but might not link them to Celiac.  That is common with us all.  At this point with the biopsy, it's more an issue of seeing how much damage you have vs. diagnosis.

Good luck to you!

Thank you so much for the thoughtful reply! I was able to meet with a Gastroenterologist and he was comfortable diagnosing me with Celiac based on blood tests alone. (The only one I'm missing is the genetic test, which I wish I'd requested. That would further solidify the diagnosis for me.) As I've been adopted a gluten free diet in the past few days, I'm realizing I actually consumed very little gluten before this diagnosis. (Because of my Type 1 Diabetes, I stick to a pretty low-carb diet to control my blood sugar and tend to avoid bread/pasta/cookies/cake/muffins/cereal/etc.) So if I were to have the endoscopy now, I'm not sure how significant the impact would be anyway. If I want to have it in the future, I can always do a gluten challenge then have it done. But for now, I'm just going gluten-free. I'm grateful I don't experience any noticeable physical symptoms when I consume gluten, but that makes it hard for me to decide where I'm going to draw the line when it comes to cross-contamination/eating out/avoiding foods that "may be processed on machinery where wheat is processed". Anyway, I'm rambling. Thanks again! I really appreciate it.

[Gemini]

18 hours ago, Olivia28 said:

Thank you so much for the thoughtful reply! I was able to meet with a Gastroenterologist and he was comfortable diagnosing me with Celiac based on blood tests alone. (The only one I'm missing is the genetic test, which I wish I'd requested. That would further solidify the diagnosis for me.) As I've been adopted a gluten free diet in the past few days, I'm realizing I actually consumed very little gluten before this diagnosis. (Because of my Type 1 Diabetes, I stick to a pretty low-carb diet to control my blood sugar and tend to avoid bread/pasta/cookies/cake/muffins/cereal/etc.) So if I were to have the endoscopy now, I'm not sure how significant the impact would be anyway. If I want to have it in the future, I can always do a gluten challenge then have it done. But for now, I'm just going gluten-free. I'm grateful I don't experience any noticeable physical symptoms when I consume gluten, but that makes it hard for me to decide where I'm going to draw the line when it comes to cross-contamination/eating out/avoiding foods that "may be processed on machinery where wheat is processed". Anyway, I'm rambling. Thanks again! I really appreciate it.

You have a very progressive and smart gastro to diagnose you on bloods only.  Many will not do that, for various reasons.  When blood work is that definitive, it is ridiculous to put people through invasive testing. I failed all the blood work on the full panel by huge numbers, had a positive gene test (it showed I have a double DQ2 gene so twice the fun!) and my weight had plummeted to 92 pounds in a very short space of time so it shouldn't take a roomful of gastro's to figure that one out.  A few doctor's down the road from diagnosis started to argue with me over an endoscopy until I showed them all my testing.  They shut up pretty quick and never questioned me again.  Considering that no other disease but Celiac will cause a positive on the EMA, not everyone needs an endoscopy, unless after following the gluten-free diet for a while, you are still having problems.

I used EnteroLab for gene testing.  They will test you without a doctor's order and the cost is relatively low.  It's a cheek swab so easy to do. I'm sure there are other labs by now who will do this. You can also have your blood work re-done in 6 months or so to see how much they have come down.  If you follow the diet correctly, they should trend downward until you reach normal.  Keep in mind that you have Type 1 and that can elevate your tTg slightly also.  Not to 182 but it might still be slightly elevated.  I have Hashi's thyroid disease and it took about a year for me to get my tTg down into low normal range because that also can elevate tTg slightly, on it's own.  Don't worry, in a couple of years, you'll be an expert in all this!  ?

[Gemini]

21 hours ago, notme! said:

( hi, gem!  ?  I was wondering whereyat! )

.  

Hey Arlene!  I'm still kicking but it's been an intense year.  We moved Mom into Assisted Living last summer and she resisted it all the way.  Made our lives hell....until she lived there for about 4 months and decided it wasn't as bad as she thought it was going to be.  They have Happy Hour!  ? But she thoroughly enjoyed trying to make us feel guilty....which we did not.  She will be 87 this year and she was trying to hide from us the fact she was having trouble taking complete care of herself.  Her health suffered but she is stubborn and did not want to move out of her house.  Guess who won that battle?  ?

This year, we are going to move my husband's mother into Assisted, from Independent.  She is 92. To say it has been busy is the understatement of the year.  Trying to do all this while still working is not recommended. So, come the end of September, I will be officially retired.  That way, I can still tend to the needs of the Mom's and actually have a life of my own.  What a concept, huh?  ?‍♀️

Hope all is well with you!

[cyclinglady]

Glad to hear from you, Gemini!  ?

[squirmingitch]

Hi Gem!

?We'll see you in September.??

[Gemini]

Hey Squirmy!

Looking forward to communicating with everyone again.  I do see that nothing ever changes.......people STILL having trouble being taken seriously by the AMA.  Well.....except for Olivia!  

There are more people in my family being diagnosed, which came as no surprise to me.  We even recently got back in touch with some of my mother’s cousins, who now live down south and guess what?  One of the adult daughters was diagnosed and she is like me......classic Celiac.  The poor thing has numerous issues due to the length of time figuring it all out.  If there is one diagnosed Celiac in a family, there will be others.....guaranteed!

[notme]

23 hours ago, Gemini said:

If there is one diagnosed Celiac in a family, there will be others.....guaranteed!

amen to that!  my brother finally got tired of the emergency room with doctors scratching their heads.  he is declared celiac and strictly gluten free.  he feels better than he has in years!  thank goodness.  also, my daughter with her 'quivering insides, mama' has finally bit the bullet and is also strictly gluten-free.  I went to her doctor's appointment following her episode of THRUSH <wtfrench vanilla) and looked at her 'celiac tests' (high negative) and I basically told the doctor that we weren't interested in her suffering for years of testing while they keep her in a dx limbo.  they wrote on her file that she was 'suspected celiac' and she is doing great!  

i'm glad things are progressing for you - you're going to retire!!  also, that is a huge burden lifted with putting those ol' ladies in assisted living.  my mother in law is widowed and she has huge property to care for, which she can pay to have it done, but it's never good enough.  so, she climbed down a steep bank to spray weeds and broke her finger in 4 places from falling.  she had surgery this morning.  we are after her to downsize at the least, but those ol' ladies are stubborn af!  lolz

I got a new laptop, so i'll be around a bit more as well.  the old one was driving me bats !!   

[Gemini]

Arlene....I am so happy that your family finally woke up and decided to have a better life.  Once you push through the fear of the gluten-free diet, it just gets better.  I wish my brother had listened to me.  He just couldn't wrap his head around the fact he most likely had Celiac, along with his Type 1.  He also had to follow a low protein diet, due to his failing kidneys so maybe it became too overwhelming for him.  But it ended up costing him his life and I still miss him terribly.  All those "what if's".

The retirement idea is still a weird thing for me.  I have always worked so giving that up is strange.  But I have no choice.  I have 2 old ladies to help with and an old cat.  ?  My poor Sophie is 14 now and she has been diagnosed with hyper thyroid.  But they all have to be taken care of and that is more important than a job I don't need anymore.  Besides, for those who still work, jobs are not the same anymore.  The workplace has been invaded by too much political correctness so it's time to go!  The fun we used to have at work would get into trouble by today's standards. ?

MIL must be downsized!  They don't realize how much stress is gone (for everyone) once they do so.  My mother fought us tooth and nail but now?  She likes it there and is happy.  She doesn't have to worry about anything.  Assisted living is NOT a nursing home.  It took moving my mother in there before she realized that. Keep working on your MIL......she'll get there.