Celiac Disease (Gluten Enteropathy)

Celiac disease is a digestive disorder that occurs in reaction to gluten, a protein found in rye, barley, wheat, and numerous foods made with these grains.

Celiac disease is an autoimmune disorder and may have a genetic component. In people with celiac disease, inflammation occurs in the small intestinal mucosa when exposed to gluten in the diet. Celiac disease is also referred to as celiac sprue, non-tropical sprue, and gluten enteropathy.

Gluten, a protein found in wheat, barley, and rye, is changed into a chemical that causes an immune response in some individuals. This leads to inflammation of the lining of the small intestine. The villi, which are the finger-like projections that make up the lining of the intestine, are destroyed, impairing the absorption of nutrients from the diet.

The malabsorption of vitamins, minerals, and other nutrients can cause damage to other organs in the body, such as the liver, bone, and brain, which rely on these nutrients for normal development and function. In children, malnutrition can lead to abnormal growth and development.

Causes of celiac disease

There is a genetic predisposition to developing celiac disease, but not all people with a family history of the disease will develop it. Other factors may contribute to the autoimmune response.

In addition to family history, celiac disease is more common in people with the following conditions:

• Type 1 diabetes
• Microscopic colitis
• Sjögren’s syndrome
• Autoimmune thyroid disease

Symptoms of celiac disease

Diarrhea and weight loss are the classic symptoms of celiac disease, but they are not present in all cases. Symptoms can vary widely in presentation and intensity. Weakness, fatigue, joint pain, and anemia are common symptoms due to chronic malabsorption of iron.

Other symptoms may include:

• Headache
• Fatigue and weakness
• Joint pain
• Numbness and tingling of the hands and feet
• Osteoporosis
• Skin rash
• Abdominal pain
• GERD and heartburn

Infants and children may experience symptoms such as diarrhea, constipation, weight loss, failure to thrive, and developmental delays.

QUESTION

Diagnosing celiac disease

Celiac disease is often diagnosed late as its symptoms are nonspecific. It may take multiple visits with complaints of recurrent abdominal pain, joint aches, or chronic anemia unresponsive to iron treatment to suspect celiac disease as a possibility.

The diagnosis involves a two-step screening process:

1. Blood test for immunoglobulin A anti-tissue transglutaminase antibody (IgA TTG). Testing for antiendomysial antibodies may also be considered.
2. If the screening blood test is positive, an endoscopy and biopsy of the duodenum lining is recommended.

The patient must eat a regular diet for weeks prior to testing. A gluten-free diet can affect the accuracy of the tests.

Once diagnosed, screening for osteoporosis may be recommended. Family members may need to be screened since celiac disease can be familial.

Treatments and diets for celiac disease

The only treatment for celiac disease and the associated inflammation of the small intestine is a lifelong gluten-free diet.

Latent celiac disease

Latent celiac disease refers to those with positive antibody blood tests but normal small bowel biopsies. Treatment with a gluten-free diet may not be necessary unless symptoms develop.

Silent celiac disease

Some individuals have positive antibody blood tests and positive small intestine biopsies but show no symptoms. Further testing may be done to look for complications. A gluten-free diet may be recommended.

Refractory celiac disease

In a small group of patients, a gluten-free diet doesn’t control symptoms. Other possible bowel diseases must be ruled out before a diagnosis of refractory celiac disease is made. Treatment may include medications used in other autoimmune disorders to decrease inflammation.

The gluten-free diet

A gluten-free diet eliminates exposure to wheat, barley, and rye, which contain gluten. It is important to read food labels carefully. Gluten-free foods should have less than 20 parts per million of gluten. Cross-contamination should be avoided during food preparation.

Many restaurants offer gluten-free options, but it’s important to confirm with the server or cook if a dish contains gluten.

Complications of celiac disease

Malabsorption can affect various organs in the body. Iron deficiency anemia, osteoporosis, and poor growth and development are common issues due to delayed diagnosis. Celiac disease is also associated with an increased risk of lymphoma and small intestine cancer, which can be reduced with a strict gluten-free diet.

Other medical problems associated with celiac disease

Celiac disease is an autoimmune disorder that can be associated with other diseases affecting organs such as the thyroid, liver, colon, and pancreas. Other conditions may include type 1 diabetes and dermatitis herpetiformis, a skin rash similar to celiac disease.

Growth failure, delayed puberty, miscarriage, and infertility may also be associated with celiac disease.

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Reference:

FDA.gov. Gluten and Food Labeling: FDA’s Regulation of "Gluten-Free" Claims.

Leonard, M.M., et al. "Celiac disease and nonceliac gluten sensitivity: a review." JAMA. 318.7 Aug. 15, 2017: 647-656.

Rubio-Tapia, A., et al. "ACG clinical guideline: diagnosis and management of celiac disease." Am J Gastroenterol. 108.5 (2013).