Celiac Disease

What is celiac disease?

In the supermarket, there are more items touting "gluten-free," why?

Those with celiac disease (CD) have strict dietary guidelines. Foods containing gluten are not allowed because of the sensitivity these individuals have to this type of protein.

Gluten is the common name for the proteins in specific grains. These proteins are found in all forms of wheat, which include durum, semolina, spelt, kamut, einkorn and faro. Other related grains are rye, barley and triticale.

Today, research indicates celiac disease to be closely correlated to a genetic disorder. CD has commonly been mis-diagnosed or under-diagnosed in the past because it can be confused with other digestive conditions.

Celiac disease was once known as a rare childhood syndrome. CD can become present in adults by being triggered in predisposed individuals.

More than two million people or about one in every 130 people in the United States are diagnosed with celiac disease, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the National Institutes of Health (NIH).

Celiac disease is an immune-mediated inflammation of the small intestine caused by sensitivity to dietary gluten and related proteins in genetically sensitive individuals. CD is also known as celiac sprue, non-tropical sprue and gluten-sensitive enteropathy.

Dr. Michael Griffen, D.O., a pediatrician practicing in Spring Hill at Sun Country Pediatrics, advises people diagnosed with celiac disease cannot eat foods that contain gluten, which can include some everyday products such as medicines, vitamins, and even some lip balms.

"Also, there is some controversy on whether oats should be added to the list, but that has not been determined at this time," Griffen added.

CD is genetic, as it can be passed from father or mother. Often CD is 'triggered,' which can happen after surgery, pregnancy, childbirth, viral infection or severe emotional stress.

"The hereditary basis of celiac disease is still not completely understood but does appear to have multiple factors," said Griffen.

Individuals can be at higher risk for being pre-disposed to celiac disease who have first-degree relatives (parent, sibling or child) diagnosed with CD, added Griffen.

"Early diagnosis of celiac disease is based best on understanding and identifying high risk groups," said Griffen.

On average, four to 12 percent of an affected person's family also has CD, according NIH.

"Individuals diagnosed with Type I diabetes are often screened for celiac disease on an every other year basis, due to the increased likely hood of CD becoming present," said Griffen.

"According to research, individuals with Down syndrome are one of the highest at risk, a 20-fold increase of risk over the general population to develop CD," advised Griffen.

Reports indicate, due to their high risk, 16 percent of those individuals with Down syndrome have CD.

For children, their risk of developing the disease is about five to 10 percent more likely if someone in the family has CD.

"The prevalence of CD is increasing because of highly sensitive and specific screening tests, which are now commercially available," said Griffen.

Research has found that for some, adults could have the disease for a decade or longer before showing signs or symptoms, also the longer a person goes undiagnosed, the greater the risk for developing long-term complications.

"Research indicates that for adults neurologic and behavioral symptoms have been associated," said Griffen, "CD and neuropsychiatric symptoms like ataxia, peripheral neuropathy, depression, anxiety or epilepsy."

Griffen added, "For children with celiac disease, clinically apparent neurological disorders are uncommon, and the information supporting the association with CD is limited."

What happens with Celiac disease?

CD is a digestive disease that damages the small intestine and interferes with absorption of nutrients from food and is a lifelong inherited autoimmune condition affecting children and adults.

CD causes the body's immune system to react to consumed glutin as a toxin. The reaction causes damage to the small intestine and does not allow food to be properly absorbed.

This cycle causes the destruction of the villi — tiny, fingerlike protrusions lining the small intestine — which allows nutrients from food to be absorbed through the walls of the small intestine into the bloodstream.

Healthy villi properly absorb nutrients from food. For CD sufferers, villi is destroyed by the toxic reaction when gluten is consumed. This leads to malnourishment because regardless of how much the person eats nutrients from digested food are not absorbed.

Even small amounts of gluten in foods can affect those with CD and cause health problems. Damage can occur to the small bowel even when there are no symptoms present.

Symptoms

According to the NIDDK, symptoms of celiac disease vary from person to person. Symptoms may occur in the digestive system or in other parts of the body.

Digestive symptoms are more common in infants and young children and may include: abdominal bloating and pain, chronic diarrhea, vomiting, constipation, pale, foul-smelling, or fatty stool, and weight loss.

Irritability is another common symptom in children. Malabsorption of nutrients during the years when nutrition is critical to a child's normal growth and development can result in other problems.

"As a pediatrician, the symptoms of most concern are patients who have a failure to thrive, persistent diarrhea and chronic constipation, recurrent abdominal pain or vomiting," said Griffen.

Also, other indicators are a delayed growth and short stature, delayed puberty, and dental enamel defects of the permanent teeth.

"For children, CD symptoms can occur as early as 6 to 24 months of age," said Griffen, "as gluten is being introduced to the child's diet."

Families should not attempt a gluten-free diet without medical consultation and advice, stated Griffen.

Adults are less likely to have digestive symptoms and may instead have experienced one or more of unexplained iron-deficiency anemia, fatigue, bone or joint pain, arthritis, bone loss or osteoporosis, depression or anxiety, tingling numbness in the hands and feet, seizures, missed menstrual periods, infertility or recurrent miscarriage, canker sores inside the mouth, and an itchy skin rash called dermatitis herpetiformis (DH).

Long-term complications include malnutrition — which can lead to anemia, osteoporosis, and miscarriage, among other problems — liver diseases, and cancers of the intestine.

DH is an intensely itchy, blistering skin rash that affects 15 to 25 percent of people with celiac disease, according to the NIDDK.

The rash usually appears on the elbows, knees, and buttocks. Most people with DH do not have digestive symptoms related to CD.

DH is diagnosed through blood tests and a skin biopsy. Generally if the antibody tests are positive from the skin biopsy with the typical findings of DH, patients are not required to have an intestinal biopsy.

Both the skin disease and the intestinal disease respond to a gluten-free diet and recur if gluten is added back into the diet.

"People with CD may have no apparent symptoms but are identified on screening by blood test, silent or subclinical disease," advised Griffen. "Other patients have had symptoms in the past and then completely recover despite maintaining a 'normal,' gluten-containing diet. This type of scenario is referred to as Latent/potential CD. "

However, it is not recommended to stop a gluten-free diet, once diagnosed with CD, he added.

The rash symptoms can be controlled with antibiotics such as dapsone, which only treats the rash, not the disease, so a gluten-free diet needs to be maintained.

Tests

Commonly, CD can be confused with irritable bowel syndrome, iron-deficiency anemia caused by menstrual blood loss, inflammatory bowel disease, diverticulitis, intestinal infections, and chronic fatigue syndrome.

"A simple blood test will show if a person has a higher than normal level of auto-antibodies," said Griffen. "These are proteins that react against the body's own cells or tissues."

Doctors test the blood for high levels of anti-tissue transglutaminase antibodies (tTGA) or anti-endomysium antibodies (EMA).

Diagnosis rates have increased due to the more reliable blood tests being available, Griffen added.

"If the blood test comes back positive, then the patient is referred to a gastroenterologist for follow-up," said Griffen. "The next step for the patient is generally an intestinal biopsy."

The intestinal biopsy is a procedure that removes tiny pieces of tissue from the small intestine to check for damage to the villi, this is performed by a gastroenterologist.

The tissue samples are obtained by using an endoscope through the patient's mouth and stomach into the small intestine.

"If the biopsy results are positive, then the patient needs to maintain a gluten-free diet and see a gastroenterologist and nutritionist regularly," said Griffen.

CD is a life long condition, Griffen added.

Treatment

At this time, a gluten-free diet is the only treatment for CD.

Doctors refer patients to seek assistance from a dietician. The dietician can help a person with CD to know what to look for on labels and ingredient lists.

Individuals need to make informed decisions on the foods they need to avoid when going to the grocery store or eating out.

For most, when following a gluten-free diet, the symptoms cease. The intestinal damage can be healed, as consuming gluten-free foods prevents future damage.

For children the healing can take as little as three to six months. However, for adults is can take several years to reverse the damage internally.

For those who experienced growth problems (short stature) and tooth enamel defects, these problems will not improve.

According to the NIDDK, some people with CD may show no improvement on the gluten-free diet as the most common cause for a poor response to the diet is a result of small amounts of gluten being consumed.

There are hidden sources where gluten can be found. This includes additives such as modified food starch, preservatives and stabilizers made with wheat. Often corn and rice products are produced in factories that also produce wheat products, therefore these foods can also be contaminated with wheat gluten.

Although rare, CD may continue for a person who is on a strict gluten-free diet. This condition is cal refractory CD.

Refractory CD occurs when a person has a severely damaged intestine that cannot heal. Because the intestine is not absorbing enough nutrients, nutrients may need to be provided directly into the bloodstream through intravenous intervention.

Researchers continue to evaluate drug treatments for refractory CD.

Since there is increase awareness about CD, there has been an increase in gluten-free foods available in the grocery stores and restaurants.

According to KidsHealth®, having CD does not mean giving up all your favorite foods. Many different gluten-free products, baking mixes, and recipes are available.

Many foods can be adapted to be gluten-free.

Dr. Michael Griffen, D.O. is a pediatrician his office location in 8391 Omaha Circle, Spring Hill, he can be contacted at 352-678-5246 or www.SunCountryPediatrics.com.