What is Celiac Disease (Celiac Sprue)?
Celiac (Greek koiliakos = abdominal) disease is an inherited malabsorption disorder affecting the small intestine, in which symptoms like diarrhea and bloating are triggered by a substance gluten, present in wheat, barley, rye and possibly oats.
Celiac disease may be mild or severe and may affect children or adults. It is considered as a life long disease and requires permanent gluten-free diet to be controlled.
Other names for celiac disease: celiac sprue, non-tropical sprue and gluten-sensitive enteropathy.
Autoimmune Mechanism of Celiac Disease
Immune system of a sensitive person recognizes gluten (and especially its part gliadin) as a foreign substance and attacks it with immune cells and antibodies. These destroy villi (microscopic finger-like projections from small intestinal mucosa) thus greatly reducing its absorption surface; absorption of fats, vitamins B12 and D, calcium and iron is mainly affected. Production of lactase, an enzyme that digests milk sugar lactose, may also be reduced, so lactose intolerance often develops in celiac disaese.
Celiac disease is not a food allergy, in which histamine, released in the intestinal mucosa and skin, causes itchy skin, facial swelling, etc., but an autoimmune disorder where antibodies and immune cells attack body’s own tissues.
Celiac disease is also not the same as gluten intolerance.
Who Gets Celiac Disease?
Celiac disease may affect any genetically predisposed person at any age – although it most often appears in children. Three conditions are needed for celiac disease to develop:
- Genetic predisposition. Only people with a certain DNA change are prone to celiac disease. If one family member has celiac disease, one out of ten other family members will also likely have it.
- Triggering event. Emotional stress, surgery, injury, pregnancy, childbirth or viral infection may all lead to change in permeability of intestinal mucosa, so gluten can enter in deeper mucosal layers where it causes inflammation. Sometimes a triggering event can’t be identified.
- Ingesting gluten. Even tiny amount of gluten, if regularly ingested, may cause intense intestinal damage.
Symptoms of Celiac Disease
Severity of small intestinal mucosal damage does not correlate with severity of symptoms. Some people, despite prominent intestinal changes, have no symptoms at all. Celiac disease may cause one or more of the following symptoms (7):
- Diarrhea, starting few hours to few days after ingesting gluten, constipation, bloating and gas, abdominal pain, nausea, heartburn, mouth ulcers
- Weight loss
- Pale skin and tiredness due to anemia from iron deficiency
- Easy bruising due to vit K deficiency
- Hair loss (alopecia) due to vit A deficiency
- Skin rash – dermatitis herpetiformis
- Joint or bone pains
Diagnosis of Celiac Disease
Diagnosis of celiac disease is confirmed by:
- Symptoms, improving after starting gluten-free diet
- Biopsy of duodenal mucosa that reveals characteristic destruction of villi – microscopic finger like protrusions of mucosa into intestinal lumen (1).
- Specific igA antibodies in the blood anti-endomysium (EMA -IgA) and anti-tissue transglutaminase (tTG IgA)are usually checked first. Positive result is not a definite proof for celiac disease so duodenal biopsy is still required for diagnosis.
- Stool IgA anti-gliadin antibody test is not reliable.
- Negative DNA test 100% excludes diagnosis of celiac disease, but positive test does not confirm it. All persons with celiac disease have specific genes (HLA DQ2 or DQ8) in their DNA. A person with these genes does not necessary have a celiac disease but has increased risk of developing it. Absence of specific genes excludes celiac disease and possibility of its development in future. DNA analysis is recommended to all 1st grade relatives of persons with celiac disease. If specific HLA genes are found, serum antibodies may be checked to detect eventual active disease in the early stage before complications (growth impairment, osteoporosis) develop.
- Blood work may show anemia, deficiency of iron, calcium, vitamin D and B12.
- Increased fats are often found by the stool fat test.
- Dual Energy X-ray Absorptiometry (DEXA) scan to evaluate bone density and thus detect eventual osteoporosis.
Prevention of Celiac Disease
A gluten-free dietis effective in most cases of celiac disease; symptoms usually disappear completely within 3-6 months in children and within 2 years in adults (2). Some patients don’t improve despite gluten-free diet, most often because they don’t stick with it strictly. The diet should be life-long, otherwise the disease may return. Infants exposed to gluten before 3rd month of age are at greater risk of developing celiac disease later in life, so exclusive breastfeeding until the 6th month is recommended (3). Local celiac support groups or online forums may provide advice about the diet and recipes(4). A skilled dietitian should be visited for the most reliable information, though.
Diet for Celiac Disease
Foodstuffs, containing gluten, NOT SAFE to eat in celiac disease:
- WHEAT, including bulgur, couscous, dinkle, durum, einkorn, emmer, farina, fu, graham flour, granary flour, grits, groats, hemp, kamut, matzo, mir, seitan, semolina, spelt, triticale, udon;
- BARLEY , which may be also in malt, flavorings, beer, ale, gin, whisky;
- OATS; most of commercially available oats are ‘contaminated’ with wheat, barley, or rye grains.
Gluten may be hidden in bran, food additives like edible starch, thickeners, preservatives, stabilizers used in frozen foods, licorice, syrups, chips, sauces, salad dressings, candies, instant foods, hot dogs and other processed foods. Gluten is even in some medicines, cosmetics, and stamps (!). Labels usually reveal if a product contains gluten or not.
Sharing food-preparing surfaces, utensils, dishes and other kitchenware with others may contaminate gluten-free food.
Persons with celiac disease may be lactose intolerant or sensitive to molds in mushrooms, mold-based cheeses or air-born molds (5).
Grains, SAFE TO EAT in celiac disease:
Seeds, nuts, legumes and tubers, like potato, are also safe (6). Gluten-free bread, pasta and other foods are available in many food stores on separate shelves.
Therapy of Celiac Disease
No therapy for celiac disease exists at the time. Vitamins and mineral replacement may be needed. Drinking enough fluid to prevent dehydration and providing enough calories to maintain proper body weight is needed.
Refractory Celiac Disease
In some individuals with celiac disease, the small intestine is so damaged that it can’t recover despite gluten-free diet; this is called refractory celiac disease. Corticosteroid therapy may help; sometimes intravenous feeding is necessary (6).
Complications of Celiac Disease
Complications of celiac disease may include:
- Iron deficiency anemia
- Vitamin B12 deficiency
- Defective tooth enamel in children
- Osteoporosis in adultsand growth impairment in children, due to calcium deficiency
- Poor muscle co-ordination (ataxia), numbness and tingling in the hands and feet (peripheral neuropathy), problems with vision, epilepsy and dementia
- Infertility, recurrent miscarriages
- Small intestinal adenocarcinoma or lymphoma are rare complications.
- Celiac Disease Foundation (celiac.org)
- Fructose Malabsorption
- Foods to Avoid in IBS
- Small Intestinal Bacterial Overgrowth (SIBO)
- Causes of Chronic Diarrhea
- Diagnostic criteria for celiac disease (edrv.endojournals.org)
- Prognosis of celiac disease (digestive.niddk.nih.gov)
- Breast feeding and celiac disease (jama.ama-assn.org)
- Gluten forum (forums.glutenfree.com)
- Sensitivity to molds in celiac disaese (csaceliacs.org)
- Safe foods in celiac disese, refractory celiac disease (celiac.org)
- Symptoms of celiac disease (health.nsw.gov.au)
- Blood test: anti-endomysium and anti-tissue transglutaminase antibodies (celiacdisease.net)