Celiac disease

Definition

Celiac disease occurs when the body reacts abnormally to gluten, a protein found in wheat, rye, barley, and oats. Gluten causes an inflammatory response in the small intestine, which damages the tissues and results in impaired ability to absorb nutrients from foods.

Description

Celiac disease—also called sprue, nontropical sprue, gluten sensitive enteropathy, celiac sprue, and adult celiac disease—may be discovered at any age. Researchers believe that a combination of genetic and environmental factors trigger the disease. Environmental events that may provoke celiac disease in those with a genetic predisposition to the disorder include surgery or a viral infection.

The disorder is more commonly found among white Europeans or those of European descent. The exact incidence of the disease is uncertain. Estimates vary from one in 5,000 to as many as one in every 300 individuals with this background. In 2002, new research in Italy followed patients with type 1 diabetes. Celiac disease is 20 times more common among these patients than in the general population, yet often goes undetected in these children. The study authors recommended celiac disease screening programs for children recently diagnosed with type 1 diabetes.

Causes & symptoms

Celiac disease is caused by an inflammatory response of the small intestine. The exact mechanism of the disorder is not clearly understood, but it is known that both heredity and the immune system play a part. When food containing gluten reaches the small intestine, the immune system begins to attack a substance called gliadin, which is found in the gluten. The resulting inflammation causes damage to the delicate finger-like structures in the intestine, called villi, where food absorption actually takes place.

The most commonly recognized symptoms of celiac disease relate to the improper absorption of food in the gastrointestinal system. The patient will have diarrhea and fatty, greasy, unusually foul-smelling stools. The patient may complain of excessive gas (flatulence), distended abdomen, weight loss, and generalized weakness.

Not all patients have these problems. Unrecognized celiac disease may cause or contribute to a variety of other conditions. The decreased ability to digest, absorb, and utilize food properly (malabsorption) may cause anemia from iron deficiency or easy bruising from a lack of vitamin K. Poor mineral absorption may result in osteoporosis, which may lead to bone fractures. Vitamin D levels may be insufficient and bring about a "softening" of bones (osteomalacia), which produces pain and bony deformities. Defects in the tooth enamel, characteristic of celiac disease, may also occur. Celiac disease may be discovered during medical tests performed to investigate failure to thrive in infants, or lack of proper growth in children and adolescents. People with celiac disease may also experience lactose intolerance because they do not produce enough of the enzyme lactase, which breaks down the sugar in milk into a form the body can absorb.

A distinctive skin rash, called dermatitis herpetiformis, may be the first sign of celiac disease. Approximately 10% of patients with celiac disease have this rash, but it is estimated that 85% or more of patients with the rash have the disease.

Because of the variety of ways celiac disease can manifest itself, it is often not discovered promptly. The condition may persist without diagnosis for so long that the patient accepts a general feeling of illness as normal. This leads to further delay in identifying and treating the disorder.

Diagnosis

If celiac disease is suspected, a blood test that looks for the antibodies that the immune system produces in celiac disease is ordered. Some experts advocate not just evaluating patients with symptoms, but using these blood studies as a screening test for high-risk individuals, such as those with relatives known to have the disorder. An abnormal result points towards celiac disease, but further tests are needed to confirm the diagnosis. Other tests may be ordered to look for nutritional deficiencies. For example, doctors may order a test of iron levels in the blood because low levels of iron (anemia) may accompany celiac disease. Doctors may also order a test for fat in the stool, since celiac disease prevents the body from absorbing fat from food.

The next step is a biopsy of the small intestine. This is usually done by a gastroenterologist, a physician who specializes in diagnosing and treating bowel disorders. It is generally performed in the office, or in an outpatient department in a hospital. The patient remains awake, but is sedated. A narrow tube is passed through the mouth, down through the stomach, and into the small intestine. A small sample of tissue is taken and sent to the laboratory for analysis. If it shows a pattern of tissue damage characteristic of celiac disease, the diagnosis is established.

Treatment

The treatment for celiac disease is a gluten-free diet (GFD). This may be easy for the doctor to prescribe, but difficult for the patient to follow. Gluten is present in any product that contains wheat, rye, barley, or oats. It helps make bread rise, and gives many foods a smooth, pleasing texture.

In addition to the many obvious places gluten can be found in a normal diet, such as breads, cereals, and pasta, there are many hidden sources of gluten. These include ingredients added to foods to improve texture or enhance flavor and products used in food packaging. Gluten may even be present on surfaces used for food preparation or cooking.

Fresh foods that have not been artificially processed, such as fruits, vegetables, and meats, are permitted as part of a GFD. Gluten-free foods can be found in health food stores, mail-order companies, and in some super-markets. Help in dietary planning is available from support groups for individuals with celiac disease. There are many cookbooks on the market specifically for those on a GFD.

Treating celiac disease with a GFD is almost always completely effective in alleviating symptoms. Secondary complications, such as anemia and osteoporosis, resolve in almost all patients. People who have experienced lactose intolerance related to their celiac disease usually see those symptoms subside as well.

Allopathic treatment

Both complementary and allopathic healthcare practitioners generally agree that a gluten-free diet is the best treatment for celiac disease.

There are a small number of patients who develop a refractory type of celiac disease, where the GFD no longer seems effective. Once the diet has been thoroughly assessed to ensure no hidden sources of gluten are causing the problem, medications may be prescribed. Steroids or immunosuppressant drugs are often used to try to control the disease.

Expected results

The physician will periodically recheck the level of antibody in the patient's blood after a diagnosis of celiac disease has been made. After several months on a GFD, the small intestine of the patient is biopsied again. If the diagnosis of celiac disease was correct, healing of the intestine will be apparent. Most experts agree that it is necessary to follow these steps in order to be sure of an accurate diagnosis.

Patients with celiac disease must keep a strict GFD as long as they live. Although the disease may have symptom-free periods, silent damage will continue to occur if the diet is not followed. Patients who do not follow their diets run higher risks of serious complications like gastrointestinal cancers, iron–deficiency anemia, and decreased bone mineral density. Celiac disease cannot be "outgrown" or cured, according to medical authorities.

Once the diet has been followed for several years, individuals with celiac disease have similar mortality rates to the general population. However, about 10% of people with celiac disease develop a cancer involving the lymphatic system (lymphoma).

Prevention

There is no way to completely prevent celiac disease. However, the key to decreasing its impact on over-all health is early diagnosis and strict adherence to the prescribed diet. Interestingly, a 2002 study of Swedish children found that the gradual introduction of glutencontaining foods into infant's diets while they are still being breast–fed can reduce the risk of celiac disease, at least in early childhood.

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