Friday, November 9, 2012

Celiac Disease

If you have celiac disease and eat foods with gluten, your immune system responds by damaging the small intestine. Gluten is a protein in wheat, rye and barley. It is found mainly in foods but may also be in other products like medicines, vitamins and even the glue on stamps and envelopes.

Gluten foods. Source: Author: Ongjulian This file is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.
Celiac disease, also spelled as Coeliac, affects each person differently. Symptoms may occur in the digestive system, or in other parts of the body. One person might have diarrhea and abdominal pain, while another person may be irritable or depressed. Irritability is one of the most common symptoms in children. Some people have no symptoms. 

May is National Celiac Awareness Month

Celiac disease is genetic. Blood tests can help your doctor diagnose the disease. Your doctor may also need to examine a small piece of tissue from your small intestine. Treatment is a diet free of gluten.

What is Celiac Disease?
Celiac disease is an autoimmune disorder of the small intestine that occurs in genetically predisposed people of all ages from middle infancy onward. Gluten is a protein found in wheat, rye, and barley. Gluten may also be used in products such as vitamin and nutrient supplements, lip balms, and some medicines. Other names for celiac disease are celiac sprue and gluten intolerance.

Your body’s natural defense system, called the immune system, keeps you healthy by fighting against things that can make you sick, such as bacteria and viruses.

Celiac disease is caused by a reaction to gliadin, a prolamin (gluten protein) found in wheat, and similar proteins found in the crops of the tribe Triticeae (which includes other common grains such as barley and rye). Upon exposure to gliadin, and specifically to three peptides found in prolamins, the enzyme tissue transglutaminase modifies the protein, and the immune system cross-reacts with the small-bowel tissue, causing an inflammatory reaction. That leads to a truncating of the villi lining the small intestine (called villous atrophy). This interferes with the absorption of nutrients, because the intestinal villi are responsible for absorption. The only known effective treatment is a lifelong gluten-free diet. While the disease is caused by a reaction to wheat proteins, it is not the same as wheat allergy.

This condition has several other names, including: c(o)eliac sprue, non-tropical sprue, endemic sprue, gluten enteropathy or gluten-sensitive enteropathy, and gluten intolerance. The term coeliac derived from the Greek κοιλιακός (koiliakós, "abdominal"), and was introduced in the 19th century in a translation of what is generally regarded as an ancient Greek description of the disease by Aretaeus of Cappadocia.

Celiac disease is hereditary, meaning it runs in families. Adults and children can have celiac disease. "An estimated 3 million Americans across all races, ages and genders suffer from celiac." 

Is Celiac Disease Serious?
Yes. Celiac disease can be very serious. It often causes long-lasting digestive problems and keeps your body from getting all the nutrition it needs. Over time, celiac disease can cause anemia, infertility, weak and brittle bones, an itchy skin rash, and other health problems.

What Are The Symptoms Of Celiac Disease?
Severe celiac disease leads to the characteristic symptoms of steatorrhoea (pale, loose and greasy stool), and weight loss or failure to gain weight (in young children). People with milder celiac disease may have symptoms that are much more subtle and occur in other organs rather than the bowel itself. It is also possible to have celiac disease without any symptoms whatsoever. Many adults with subtle disease only have fatigue or anemia.

Other symptoms of celiac disease may include:
  • stomach pain
  • gas
  • diarrhea
  • extreme tiredness
  • change in mood
  • weight loss
  • a very itchy skin rash with blisters
  • slowed growth
Some people with celiac disease may not feel sick or have symptoms. Or if they feel sick, they don’t know celiac disease is the cause. Most people with celiac disease have one or more symptoms. Not all people with celiac disease have digestive problems. Having one or more of these symptoms does not always mean a person has celiac disease because other disorders can cause these symptoms.

The diarrhea that is characteristic of celiac disease is (chronic) pale, voluminous and malodorous. Abdominal pain and cramping, bloatedness with abdominal distension (thought to be due to fermentative production of bowel gas) and mouth ulcers may be present. As the bowel becomes more damaged, a degree of lactose intolerance may develop. Frequently, the symptoms are ascribed to irritable bowel syndrome (IBS), only later to be recognized as celiac disease; a small proportion of patients with symptoms of IBS have underlying celiac disease, and screening for celiac disease is recommended for those with IBS symptoms.

Celiac disease leads to an increased risk of both adenocarcinoma (small intestine cancer) and lymphoma of the small bowel (enteropathy-associated T-cell lymphoma or EATL). This risk returns to baseline with diet. Longstanding and untreated disease may lead to other complications, such as ulcerative jejunitis (ulcer formation of the small bowel) and stricturing (narrowing as a result of scarring with obstruction of the bowel).

The changes in the bowel make it less able to absorb nutrients, minerals and the fat-soluble vitamins A, D, E, and K.
  • The inability to absorb carbohydrates and fats may cause weight loss (or failure to thrive/stunted growth in children) and fatigue or lack of energy.
  • Anemia may develop in several ways: iron malabsorption may cause iron deficiency anaemia, and folic acid and vitamin B12 malabsorption may give rise to megaloblastic anaemia.
  • Calcium and vitamin D malabsorption (and compensatory secondary hyperparathyroidism) may cause osteopenia (decreased mineral content of the bone) or osteoporosis (bone weakening and risk of fragility fractures).
  • A small proportion have abnormal coagulation due to vitamin K deficiency and are slightly at risk for abnormal bleeding.
  • Celiac disease is also associated with bacterial overgrowth of the small intestine, which can worsen malabsorption or cause malabsorption despite adherence to treatment.

Celiac disease has been linked with a number of conditions. In many cases, it is unclear whether the gluten-induced bowel disease is a causative factor or whether these conditions share a common predisposition.
  • IgA deficiency is present in 2.3% of patients with celiac disease, and in turn, this condition features a tenfold increased risk of celiac disease. Other features of this condition are an increased risk of infections and autoimmune disease.
  • Dermatitis herpetiformis; this itchy cutaneous condition has been linked to a transglutaminase enzyme in the skin, features small-bowel changes identical to those in celiac disease, and may respond to gluten withdrawal even if there are no gastrointestinal symptoms.
  • Growth failure and/or pubertal delay in later childhood can occur even without obvious bowel symptoms or severe malnutrition. Evaluation of growth failure often includes celiac screening.
  • Recurrent miscarriage and unexplained infertility.
  • Hyposplenism (a small and underactive spleen); this occurs in about a third of cases and may predispose to infection given the role of the spleen in protecting against bacteria.
  • Abnormal liver function tests (randomly detected on blood tests).

Celiac disease is associated with a number of other medical conditions, many of which are autoimmune disorders: diabetes mellitus type 1, autoimmune thyroiditis, primary biliary cirrhosis, and microscopic colitis.

A more controversial area is a group of diseases in which anti-gliadin antibodies (an older and non-specific test for celiac disease) are sometimes detected, but no small bowel disease can be demonstrated. Sometimes, these conditions improve by removing gluten from the diet. This includes cerebellar ataxia, peripheral neuropathy, schizophrenia and autism.

Other Grains
Wheat subspecies (such as spelt, semolina and durum) and related species such as barley, rye, triticale and Kamut also induce symptoms of celiac disease. A small minority of celiac patients also react to oats. It is most probable that oats produce symptoms due to cross contamination with other grains in the fields or in the distribution channels. Therefore, oats are generally not recommended. However, many companies assure the 'purity' of oats, and are therefore still able to be consumed through these sources.

Other cereals such as maize (corn), millet, sorghum, tef (Eragrostis tef), rice, and wild rice are safe for patients to consume, as well as non cereals such as amaranth, quinoa or buckwheat. Non-cereal carbohydrate-rich foods such as potatoes and bananas do not contain gluten and do not trigger symptoms.

How Is Celiac Disease Diagnosed?
There are several tests that can be used to assist in diagnosis. The level of symptoms may determine the order of the tests, but all tests lose their usefulness if the patient is already taking a gluten-free diet. Intestinal damage begins to heal within weeks of gluten being removed from the diet, and antibody levels decline over months. For those who have already started on a gluten-free diet, it may be necessary to perform a re-challenge with some gluten-containing food in one meal a day over 2–6 weeks before repeating the investigations.

Combining findings into a prediction rule to guide use of endoscopic biopsy reported a sensitivity of 100% (it would identify all the cases) in a population of subjects with a high index of suspicion for celiac disease, with a concomitant specificity of 61% (a false positive rate of 39%). The prediction rule recommends that patients with high-risk symptoms or positive serology should undergo endoscopic biopsy of the second part of the duodenum. The study defined high-risk symptoms as weight loss, anemia (haemoglobin less than 120 g/l in females or less than 130 g/l in males), or diarrhea (more than three loose stools per day).

Blood Tests
Serological blood tests are the first-line investigation required to make a diagnosis of celiac disease. Antiendomysial antibodies of the immunoglobulin A (IgA) type can detect celiac disease with a sensitivity and specificity of 90% and 99%, respectively. Serology for anti-tTG antibodies was initially reported to have a higher sensitivity (99%) and specificity (>90%) for identifying celiac disease. However, it is now thought to have similar characteristics to anti-endomysial antibody. Modern anti-tTG assays rely on a human recombinant protein as an antigen. tTG testing should be done first as it is an easier test to perform. An equivocal result on tTG testing should be followed by antibodies to endomysium.

Because of the major implications of a diagnosis of celiac disease, professional guidelines recommend that a positive blood test is still followed by an endoscopy/gastroscopy and biopsy. A negative serology test may still be followed by a recommendation for endoscopy and duodenal biopsy if clinical suspicion remains high due to the 1 in 100 "false-negative" result. As such, tissue biopsy is still considered the gold standard in the diagnosis of celiac disease.

Historically three other antibodies were measured: anti-reticulin (ARA), anti-gliadin (AGA) and anti-endomysium (EMA) antibodies. Serology may be unreliable in young children, with anti-gliadin performing somewhat better than other tests in children under five. Serology tests are based on indirect immunofluorescence (reticulin, gliadin and endomysium) or ELISA (gliadin or tissue transglutaminase, tTG).

Guidelines recommend that a total serum IgA level is checked in parallel, as celiac patients with IgA deficiency may be unable to produce the antibodies on which these tests depend ("false negative"). In those patients, IgG antibodies against transglutaminase (IgG-tTG) may be diagnostic.

Antibody testing and HLA testing have similar accuracies. However, widespread use of HLA typing to rule out celiac disease is not currently recommended.

An upper endoscopy with biopsy of the duodenum (beyond the duodenal bulb) or jejunum is performed. It is important for the physician to obtain multiple samples (four to eight) from the duodenum. Not all areas may be equally affected; if biopsies are taken from healthy bowel tissue, the result would be a false negative.

Most patients with celiac disease have a small bowel that appears normal on endoscopy; however, five concurrent endoscopic findings have been associated with a high specificity for celiac disease: scalloping of the small bowel folds, paucity in the folds, a mosaic pattern to the mucosa (described as a "cracked-mud" appearance), prominence of the submucosa blood vessels, and a nodular pattern to the mucosa.

Until the 1970s, biopsies were obtained using metal capsules attached to a suction device. The capsule was swallowed and allowed to pass into the small intestine. After x-ray verification of its position, suction was applied to collect part of the intestinal wall inside the capsule. Often-utilized capsule systems were the Watson capsule and the Crosby-Kugler capsule. This method has now been largely replaced by fibre-optic endoscopy, which carries a higher sensitivity and a lower frequency of errors.

If your blood test results show you might have celiac disease, your doctor will perform an upper endoscopy with biopsy of the duodenum, which involves taking a tiny piece of tissue from your small intestine. A biopsy may be performed at a hospital or outpatient center.

Your doctor will provide you instructions about how to prepare for a biopsy. Generally, no eating or drinking is allowed 8 hours before a biopsy. Smoking and chewing gum are also prohibited during this time. Tell your doctor about any health conditions you may have, especially heart and lung problems, diabetes, and allergies. Also tell your doctor about any medicines you take. You may be asked to stop taking them for a short time before and after the test.

To perform the biopsy, the doctor inserts a long, narrow tube into your mouth, down through your stomach, and into your small intestine. At the end of the tube are small tools that the doctor uses to snip out a bit of tissue. The tissue will then be viewed with a microscope to look for signs of celiac disease damage. You will take medicine before the biopsy that makes you sleepy and keeps you from feeling any pain. Many people sleep through the procedure.

Other Diagnostic Tests
At the time of diagnosis, further investigations may be performed to identify complications, such as iron deficiency (by full blood count and iron studies), folic acid and vitamin B12 deficiency and hypocalcaemia (low calcium levels, often due to decreased vitamin D levels). Thyroid function tests may be requested during blood tests to identify hypothyroidism, which is more common in people with celiac disease.

Osteopenia and osteoporosis, mildly and severely reduced bone mineral density, are often present in people with celiac disease, and investigations to measure bone density may be performed at diagnosis, such as dual-energy X-ray absorptiometry (DXA) scanning, to identify risk of fracture and need for bone protection medication.

How Is Celiac Disease Treated?

At present, the only effective treatment is a lifelong gluten-free diet. No medication exists that will prevent damage or prevent the body from attacking the gut when gluten is present. Strict adherence to the diet allows the intestines to heal, leading to resolution of all symptoms in most cases and, depending on how soon the diet is begun, can also eliminate the heightened risk of osteoporosis and intestinal cancer and in some cases sterility. Dietitian input is generally requested to ensure the patient is aware which foods contain gluten, which foods are safe, and how to have a balanced diet despite the limitations. In many countries, gluten-free products are available on prescription and may be reimbursed by health insurance plans.

The diet can be cumbersome; failure to comply with the diet may cause relapse. The term gluten-free is generally used to indicate a supposed harmless level of gluten rather than a complete absence. The exact level at which gluten is harmless is uncertain and controversial. A recent systematic review tentatively concluded that consumption of less than 10 mg of gluten per day is unlikely to cause histological abnormalities, although it noted that few reliable studies had been done.

Regulation of the label gluten-free varies widely by country. In the United States, the Food and Drug Administration (FDA) issued regulations in 2007 limiting the use of "gluten-free" in food products to those with less than 20 ppm of gluten. The current international Codex Alimentarius standard allows for 20 ppm of gluten in so-called "gluten-free" foods. Gluten-free products are usually more expensive and harder to find than common gluten-containing foods. Since ready-made products often contain traces of gluten, some celiacs may find it necessary to cook from scratch.

Even while on a diet, health-related quality of life (HRQOL) may be lower in people with coeliac disease. Studies in the United States have found that quality of life becomes comparable to the general population after staying on the diet, while studies in Europe have found that quality of life remains lower, although the surveys are not quite the same. Men tend to report more improvement than women. Some have persisting digestive symptoms or dermatitis herpetiformis, mouth ulcers, osteoporosis and resultant fractures. Symptoms suggestive of irritable bowel syndrome (IBS) may be present, and there is an increased rate of anxiety, fatigue, dyspepsia (indigestion) and musculoskeletal pain.

Refractory Disease
A tiny minority of patients suffer from refractory disease, which means they do not improve on a gluten-free diet. This may be because the disease has been present for so long that the intestines are no longer able to heal on diet alone, or because the patient is not adhering to the diet, or because the patient is consuming foods that are inadvertently contaminated with gluten. If alternative causes have been eliminated, steroids or immunosuppressants (such as azathioprine®) may be considered in this scenario.

Eating, Diet, and Nutrition
A dietitian can help you select gluten-free foods. A dietitian is an expert in food and healthy eating. You will learn how to check labels of foods and other items for gluten.  A dietitian can help you learn what other foods you can and can’t eat on a gluten-free diet.

Gluten-Free Diet Guide for People with Newly Diagnosed Celiac Disease Fact Sheet

Foods that Contain Gluten:
  • Wheat
    • including einkorn, emmer, spelt, kamut
    • Wheat starch, wheat bran, wheat germ, cracked wheat, hydrolyzed wheat protein

  • Barley
  • Rye
    • Triticale (a cross between wheat and rye)

Other Wheat Products that Contain Gluten:
  • Bromated flour, 
  • Durum flour, 
  • Enriched flour, 
  • Farina, 
  • Graham flour, 
  • Phosphated flour, 
  • Plain flour, 
  • Self-rising flour, 
  • Semolina, 
  • White flour

Processed Foods that May Contain Wheat, Barley, or Rye*:
  • Bouillon cubes, 
  • Brown rice syrup, 
  • Chips/potato chips, 
  • Candy, 
  • Cold cuts, hot dogs, salami or sausage, 
  • Communion wafer, 
  • French fries, 
  • Gravy, 
  • Imitation fish, 
  • Matzo, 
  • Rice mixes, 
  • Sauces, 
  • Seasoned tortilla chips, 
  • Self-basting turkey, 
  • Soups, 
  • Soy sauce, 
  • Vegetables in sauce
*Most of these foods can be found gluten-free. When in doubt, check with the food manufacturer.
Source: Thompson T. Celiac Disease Nutrition Guide, 2nd ed. Chicago: American Dietetic Association; 2006. © American Dietetic Association. Adapted with permission. For a complete copy of the Celiac Disease Nutrition Guide, please visit Academy of Nutrition and Dietetics.

Points to Remember:
  • Celiac disease is an immune disease in which people can’t eat gluten or use items with gluten in them.
  • Celiac disease harms the small intestine.
  • People with untreated celiac disease can’t get needed nutrients.
  • Without treatment, people with celiac disease can develop other health problems.
  • Celiac disease is diagnosed by blood tests and a biopsy of the small intestine.
  • The only treatment for celiac disease is to avoid gluten.
  • A dietitian can help people choose the right foods.

Hope Through Research
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports research on celiac disease. Researchers are studying new options for diagnosing celiac disease, including capsule endoscopy, which involves patients swallowing a capsule containing a tiny video camera that records images of the small intestine.

Several drug treatments for celiac disease are being studied. Researchers are also studying a combination of enzymes—proteins that aid chemical reactions in the body—that might change gluten in ways that prevent it from causing an immune reaction before it enters the small intestine.

Scientists are also developing educational materials for standardized medical training to raise awareness among health care providers. The hope is that increased understanding and awareness will lead to earlier diagnosis and treatment of celiac disease.

External Links

Celiac Disease - American Academy of Family Physicians.
What Is Celiac Disease? - Celiac Sprue Association.

learn How Celiac Disease Is Diagnosed - University of Chicago Celiac Disease Center.
Celiac Disease Tests - American Association for Clinical Chemistry.
Signs and Symptoms of Celiac Disease - Celiac Sprue Association.
Symptoms of Celiac Disease - University of Chicago Celiac Disease Center.

Treatment of Celiac Disease - Celiac Sprue Association.

Celiac Disease Diet: How Do I Get Enough Grains? - Mayo Foundation for Medical Education and Research.
Gluten-Free Diet Guide for Families - North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.
Gluten-Free Recipes - Celiac Sprue Association.
Quick Start Diet Guide for Celiac Disease - Gluten Intolerance Group.

Emotional Adjustment for Parents - Children's Hospital Boston.

Disease Management
Follow-Up Testing - University of Chicago Celiac Disease Center.
Maximizing Your Health - Celiac Sprue Association.
Tips For Dining Away from Home - Gluten Intolerance Group.
Traveling with Celiac Disease - National Digestive Diseases Information Clearinghouse.

Specific Conditions
Dermatitis Herpetiformis - Gluten Intolerance Group.

Related Issues
Allergies and Intolerance - University of Chicago Celiac Disease Center.
Celiac Disease and Associated Autoimmune Diseases: The Connection - Gluten Intolerance Group.
Celiac Disease and Thyroid Disease: The Connection - Gluten Intolerance Group.
Dental Enamel Defects and Celiac Disease - National Institute of Diabetes and Digestive and Kidney Diseases.
Diabetes and Celiac Disease - Gluten Intolerance Group.
Gluten in Medications, Vitamins and Supplements - Celiac Disease Foundation.
Gluten Sensitivity: Can gluten intolerance make me feel sick? - Gluten Intolerance Group.
Lactose Intolerance and Celiac Disease - Celiac Disease Foundation.
What People with Celiac Disease Need to Know about Osteoporosis - National Institute of Arthritis and Musculoskeletal and Skin Diseases. 

Celiac Disease and Gluten-Free Diet Videos - Celiac Sprue Association.
Celiac Family Health Education Video Series - Children's Hospital Boston.

Clinical Trials Celiac Disease - National Institutes of Health.

Genetic Testing for Celiac Disease - University of Chicago Celiac Disease Center. 

Grains and Flours Glossary - Celiac Sprue Association.

Celiac Centers in the United States - Celiac Sprue Association.
Links to Other Celiac Disease Organizations - National Institute of Diabetes and Digestive and Kidney Diseases.
Find a Pediatric Gastroenterologist - North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.
Find a Registered Dietitian - Academy of Nutrition and Dietetics.

Celiac Sprue Association.
Gluten Intolerance Group.
Celiac Central - National Foundation for Celiac Awareness (NFCA).

Law and Policy
A Glimpse at 'Gluten-Free' Food Labeling - Food and Drug Administration.

Celiac Disease (For Children) - Nemours Foundation.
Emotional Adjustment for Siblings - Children's Hospital Boston.
Pediatric Celiac Disease - North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Celiac Disease (For Teens) - Nemours Foundation.

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