Written by: Hanan Khalaf, RPH
What is celiac disease ?
Celiac disease, also known as celiac sprue, nontropical sprue, and gluten-sensitive enteropathy, is an autoimmune disease that affect the small intestine within the digestive system. It leads to destruction of villi, which are small protrusions in the small intestine responsible for food absorption, and hence lead to malabsorption with resultant signs and symptoms of nutritional, vitamin, and mineral deficiencies. It is considered an autoimmune because the body attacks those villi in the small intestine as if they are foreign objects, in response to gluten exposure or in a more specific way to gliadin (an amino acid within gluten). Gluten is a substance found in wheat, rye, barley, spelt, kamut, and triticale.
Who is most likely affected by this disease?
Celiac disease is a genetic disorder, means it runs in families. It is estimated that Celiac disease affect 1% of the population worldwide, yet around 97% of these are undiagnosed.
What are the symptoms of celiac disease?
Persons affected with this disease might develop no symptoms at all or might have symptoms not related to gastrointestinal tract at all. On the other hand, when symptoms develop they might start during childhood, or might only show during adulthood. Some conditions might contribute to its appearance for the first time like surgery, pregnancy, childbirth, viral infection, or severe emotional stress.
Symptoms might vary between children and adults and include:
- Recurring bloating, gas, or abdominal pain
- Chronic diarrhea or constipation or both
- Unexplained weight loss or weight gain
- Pale, foul-smelling stool
- Unexplained anemia due to disturbed vitamin B12 and Iron absorption.
- Bone or joint pain sometimes even fractures due to impaired absorption of vitamin D and calcium.
- Behavior changes/depression/irritability
- Vitamin K Deficiency and associated hemorrhage.
- Fatigue, weakness or lack of energy due to impaired absorption of minerals.
- Delayed growth or onset of puberty
- Failure to thrive (in infants)
- Missed menstrual periods
- Infertility male & female
- Spontaneous miscarriages
- Canker sores inside the mouth
- Tooth discoloration or loss of enamel.
- A blistering, itchy skin rash mostly on the elbows and knees, called dermatitis herpetiformis.
What is latent and silent CD?
Both terms refer to patients who have inherited the gene that predispose them to the disease but have not yet develop the signs and symptoms of the disease.
Latent CD refers specifically to those patients who have abnormal antibody testing but they have normal intestinal lining and are free of symptoms. Such patients might develop signs and symptoms of the disease any time later in life.
Silent CD refers to patients who have abnormal antibody testing and show some loss of villi in the small intestine but have no signs and symptoms even though they are on normal diet (not gluten-free). Similar to those with latent CD, patients with silent CD can develop signs and symptoms any time in their life. It is usually diagnosed by screening asymptomatic individuals from groups at risk such as first degree relatives of CD patients.
How can celiac disease be diagnosed?
In addition to the history, definite diagnosis can be accomplished by:
1. A blood test for iron, folic acid and calcium level.
2. A blood test that detects some antibodies commonly found in this condition (since this is an autoimmune disease). The most specific ones are anti-endomysial antibody and anti-tissue transglutaminase antibodies that are produced by the body against its own tissues. If these antibodies are abnormally elevated, then there is more than 95% chance to have CD.
A less reliable one is the anti-gliadin antibody, which is produced against gliadin in diet and tend to give false-positive results. Its is useful, however, in monitoring the response to treatment.
3. An endoscopy with biopsy is often required to confirm the diagnosis.
Diagnosis can be reached at any age. In infants, diagnosis is mostly done when they are shifted to gluten-containing diets as cereals and bread.
Should antibody testing be generalized?
Whether it is justified to generalize antibody screening or not, is an issue that should be determined by the health authority of the individual country. In Italy, for example, where CD is common, all children are screened. In USA, it is not recommended to screen healthy individuals. Antibody blood tests are only recommended for individuals with a higher likelihood than normal of having celiac disease. These patients are:
- Patients with chronic diarrhea (that doesn't resolve in three weeks), increased amount of fat in the stool (steatorrhea), and weight loss.
- Patients with excess gas, bloating, and abdominal distension.
- First and second degree relatives of patients who have celiac disease.
- Children with growth retardation.
- Patients with unexplained iron deficiency anemia.
- Patients with skin rashes suggestive of dermatitis herpetiformis.
- Patients with recurrent painful mouth sores (aphthous stomatitis).
- Patients with diseases known to be associated with CD as mentioned in the following question.
What other diseases can be associated with CD?
Some disorders appear to have a higher incidence among people with celiac disease than in the general population. Such as
- Dermatitis Herpetiformis.
- Autoimmune thyroid disease.
- Insulin-dependent diabetes (juvenile-onset or type1 diabetes).
- Rheumatoid arthritis.
- Systemic lupus.
- Down syndrome.
- Primary biliary cirrhosis.
- Intestinal lymphoma.
Treatment for CD will not cure these conditions, but might help control the disease.
What are the complications of CD?
- Fertility problems.
- Intrauterine growth retardation.
- Short stature.
- Dental enamel hypoplasia.
- Dematitis herpetiformis.
- Gluten ataxia and other neurological disturbances.
- A slightly increased risk of developing bowel cancer, intestinal lymphoma and cancer of the oesophagus.
How can Celiac disease be treated?
There is no cure for CD and the only definite treatment is gluten-free diet.
Patients with CD vary in their tolerance to gluten. Some are able to consume small amounts with no problems, others might develop massive diarrhea with exposure to minute amounts only.
So the key issue is to avoid gluten in diet which means:
1. Avoid all foods made from wheat, rye, and barley. Examples are breads, cereals, pasta, crackers, cakes, pies, cookies, and gravies.
2. Oats do not contain gluten or contain small amounts only, but are often contaminated due to growing and processing with wheat.
3. Gluten is found hidden in some processed food as canned soups, ice cream, malt vinegar, candy bars, soy sauce, instant coffee, luncheon meats, flavored yogurt (plain yogurt is usually gluten-free) , sausages, ketchup, mustard, salad dressings, processed and canned meat, mayonnaise, onion rings, and crisps as chips offered in restaurants, and beer. For a more comprehensive list of food check the following link
4. Cooking oil (mixed vegetable oil) can contain wheat-germ oil, so use sunflower or olive oil or any other oil that does not contain wheat-germ oil.
5. Be aware of medicines that might contain gluten including vitamins and some cosmetics as lipsticks. Check with your pharmacist before consuming any OTC product.
6. Allowed foods include all fruits, salads, vegetables, potatoes, rice, maize, nuts, red meat, chicken, fish, eggs and dairy products (for those who are not lactose-intolerant).
Gluten-free products are available through many websites as the following link.
Many sites also offer recipes for gluten-free food as the following link.
7. It is important to take vitamins and minerals to replace the loss due to malabsorption.
With strict gluten-free diet improvement of symptoms will start within weeks, although many patient report improvement starting 48hours of strict diet. Improvement of symptoms will be followed by regeneration of intestinal villi which might take months to years.
On the other hand, the use of gluten-free diet will reduce all possible complications and associated conditions. Studies have shown that sticking to a gluten-free diet for five years or more reduces the risk of all cancers associated with celiac disease to that of the general population.