Know More About Celiac Disease

History

This disease affected people as early as 1st century AD. It is supported by a study on a skeleton of that period’s young & wealthy woman in a tomb at the Cosa archaeological site on the Tuscan coast in Italy. She had short height, clinical history of anemia, and a decreased bone mass with evidence of osteoporosis and bone fragility, all the classical signs of celiac disease. DNA analysis had shown that the woman carried an immune system gene HLA-DQ2 that is associated with celiac disease.

The term “Celiac” is derived from a Greek word “Koiliakos” meaning suffering of bowel & was introduced in 250 AD by Aretaeus of Cappadocia.

In 1888, Dr. Samuel Gee of Great Ormond Street Hospital for children in United Kingdom was one of many physicians of the time to experiment with diets to relieve the symptoms of celiac disease. He also documented improvement in a patient when introduced to gluten free diet who suffered relapse when gluten was reintroduced.

The history of celiac disease is still being written today, as new research continues. It is essential to know that it is not a new disease, even though it may seem so due to recent increases in familiarity.


Introduction

Celiac disease is considered to be the most common chronic condition affecting about 1% of the population worldwide.

It is an autoimmune enteropathy (Bowel Disease) occurring in genetically susceptible individuals, triggered by viral/ bacterial infection, pregnancy or consumption of dietary gluten which is found in certain grains (wheat, barley & rye). It can occur at any age.

The intake of gluten in these individuals stimulates the t-cells (white blood cells essential for the healthy immunity) to inflame the mucosa of the small intestine and destroy the villi, small finger like projections meant for absorption of nutrients from the food we eat, resulting in nutritional deficiencies. People with a first-degree relative with celiac disease (parent, child and sibling) have a 1 in 10 risk of developing celiac disease. Celiac disease is also known as coeliac disease, celiac sprue, non-tropical sprue, and gluten sensitive enteropathy.


Symptoms

The symptoms of celiac disease may vary from very subtle to severe. Some persons with disease may have no symptoms others may have non-classical symptoms also.

The classical symptoms of celiac disease have been exhibited by only about 40% of the patients, which are

  • Fatigue
  • Listlessness
  • Diarrhea
  • Weight loss

If these symptoms persist for few months, you would be advised blood tests by your doctor. And the most common finding of this test is iron deficiency anemia. This anemia is caused by non-absorption of iron from the food. It is possible that other nutrients such as calcium & proteins are also not properly absorbed.

The recent researches have made it clear that Celiac Disease is a multisystem disorder. It has been proven that in CD small intestine becomes permeable (also called leaky gut) & gluten ingested penetrates through its wall and therefore causes other extra-intestinal systemic conditions as well. This leaky gut along with malnutrition can lead to many complications such as:

  • Anemia
  • Failure to thrive ( in infants)
  • Stunted growth ( in children)
  • Dental enamel deficiency
  • Osteoporosis/ Osteopenia/ Rickets in children
  • Delayed puberty onset
  • Neurological symptoms like Ataxia (loss of control of body movements), Seizures, ADHD (Attention Deficit Hyperactivity Disorder), Peripheral Neuropathy, Headaches, Depression etc.
  • Recurrent fetal loss
  • Infertility
  • Malignancy
  • Lactose intolerance


Difference between Celiac disease, Non-celiac gluten sensitivity and Wheat allergy

CD is immune mediated inflammation of the bowel caused by the protein in wheat, barley& rye in genetically predisposed individuals. On the other hand NCGS is characterized by the GI or other symptoms that respond positively to gluten free diet. The main difference between these two conditions is that those with NCGS show no change in the mucosa of small bowel in the form of inflammation or destruction of villi. Since most of the NCGS patients are self-diagnosed, the prevalence NCGS is impossible to determine though it is estimated in between 5% to 13% of the global population.

Wheat allergy can cause GI symptoms but mostly the symptoms are of sudden onset such as difficulty in swallowing, skin rashes & shortness of breath after intake of wheat even in small amount. In severe cases, it can be as detrimental as life threatening. Patients of wheat allergy respond well to wheat free diet. Patient of wheat allergy may have CD or NCGS along with.

Diagnosis

People generally suffer for a long time before being diagnosed. The first step to a diagnosis begins with lab tests. Don’t change the diet until tests are done. If you don’t take gluten, the antibodies may not be present to indicate celiac disease, even if you have it.

  • Serological test look for three antibodies common in celiac disease -
    • Anti-tissue transglutaminase (tTG) antibodies
    • Endomysial antibodies (EMA)
    • Deamidatedgliadin peptide (DGP) antibodies
  • Small bowel biopsy is essential to confirm diagnosis. This involves a gastroscopy procedure in which several tiny samples (biopsies) of the small bowel are taken. The biopsies are examined under a microscope to confirm the presence of villous atrophy. This test is usually performed in an outpatient facility, and is recommended for the final diagnosis.
  • Gene (HLA) testing is a useful test in selected cases when the diagnosis of celiac disease is unclear. Over 99% of people affected by celiac disease have the HLA DQ2, HLA DQ8, or parts of these genes. Therefore, a negative test for these genes effectively rules out celiac disease. The gene test on its own cannot diagnose celiac disease. Only 1 in 30 people who have HLA DQ2 or HLA DQ8 will develop celiac disease. This test is recommended to persons on gluten free diet, first degree relatives of people with celiac disease and people with unclear small bowel biopsy result.

Treatment

Once the diagnosis is confirmed, challenge of management begins. Strict gluten free for lifetime is the only standard treatment thus far. Villi further destruction stops after starting gluten free diet and healing mechanism starts and mostly within few months, intestinal mucosa become normal. Patient starts feeling improvement in symptoms. If you are not seeing much improvement then re-evaluate your diet to make sure that you are not taking anything that may contain gluten.

Initially you may be advised to take some multivitamin, iron and calcium supplements to cover up the deficit.

Myths

  • You can outgrow celiac disease. Celiac disease is hereditary autoimmune disorder that becomes asymptomatic after a period on strict gluten free diet. It doesn’t mean that you have outgrown it.
  • Little bit of gluten once in a while will not harm. It has been suggested that 100 milligrams of gluten daily causes sufficient damage to the villi of intestine, a recent study has calculated it be 3o milligrams. Practically it’s is less than a teaspoon of birthday cake.
  • You don’t need a biopsy. Biopsy is gold standard for the diagnosis of celiac disease. Putting the patient on gluten free diet without biopsy is not advised.
  • Gluten is penetrated through skin. Gluten needs immune cells of the intestine to react and cause inflammation. So as long as one doesn’t have anything orally it cannot cause intestinal damage. So you have to be careful while choosing lipsticks or lip liners etc.
  • You can get celiac disease through blood transfusion. Antibodies found in the blood of celiac patient can neither cause damage nor provide protection from celiac disease.

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