Celiac
Disease is:
- A genetic,
inheritable disease.
- Linked to
genetically transmitted histocompatibility cell
antigens (HLA DR3-DQ2, DR5/7 DQ2, and DR4-DQ8).
- COMMON.
Approximately 1 in 133 people have CD, however,
only about 3% of these have been diagnosed. This
means that there are over 2.1 million undiagnosed
celiacs in the United States.
- Characterized by
damage to the mucosal lining of the small
intestine which is known as villous atrophy.
- Responsible for the
malabsorption of nutrients resulting in
malnutrition.
- Linked to skin
blisters known as dermatitis herpetiformis (DH).
- Not age-dependent.
It may become active at any age.
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Celiac Disease is
NOT:
- simply a food
allergy.
- an idiosyncratic
reaction to food proteins (mediated by IgE).
- typified by a rapid
histamine-type reaction (such as bronchospasm,
urticaria, etc.).
The term
"gluten" is, in a sense, a generic term for
the storage proteins that are found in grains. In
reality, each type of protein - gliadin in wheat,
secalin in rye, hordein in barley, avenin in oats,
zein in corn and oryzenin in rice - is slightly
different from the others. The "gluten" in
wheat, rye, barley, and in a much lower amount, oats,
contains particular amino acid sequences that are
harmful to persons with celiac disease. The damaging
proteins are particularly rich in proline and
glutamine (especially the amino acid sequences which
are in the following orders: Pro-Ser-Gln-Gln and
Gln-Gln-Gln-Pro). As peptides, some such as 33-MER,
cannot be broken down any further. In people with
celiac disease, 33-MER stimulates T-cells to produce
antibodies. The antibodies, in turn, attack the villi
in the small intestine, reducing their ability to
absorb nutrients. It is important to note that these
sequences are NOT found in the proteins of corn and
rice.
Celiac disease cannot be 'caught,' but rather the
potential for CD may be in the body from birth. Its
onset is not confined to a particular age range or
gender, although more women are diagnosed than men. It
is not known exactly what activates the disease,
however three things are required for a person to
develop CD:
A genetic disposition – being born with the
necessary genes. The Human Leukocyte Antigen (HLA)
genes specifically linked to celiac disease are DR3,
DQ2 and DQ8.
A trigger – some environmental, emotional or
physical event in one’s life. While triggering
factors are not fully understood, possibilities
include, but are not limited to:
adding solids to a baby’s diet, going through
puberty, endu.
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Symptoms
Celiac Disease may appear at any time in the life of a
person with a hereditary pre-disposition. Many
patients are asymptomatic for years, with the disease
becoming active for the first time after surgery,
viral infection, severe emotional stress, pregnancy or
childbirth. Symptoms of Celiac Disease are extremely
varied and cam mimic other bowel disorders and even
psychiatric complaints. Infants, toddlers and children
often exhibit growth failure, vomiting, bloated
abdomen and behavioral changes.
Classic symptoms may include:
- abdominal cramping,
intestinal gas, distention and bloating
- chronic diarrhea or
constipation (or both)
- steatorrhea --
oily stools
- anemia -
unexplained, due to folate, B12, B6, or iron
deficiency (or all)
- weight loss with
large appetite, or weight gain
Treatment of celiac
disease
Unlike autoimmune diseases
in which the precipitating antigen either is not
identified or if identified can not be removed, the
antigen precipitating celiac disease i.e. gluten can
be removed from the diet. This sounds easier than done
as wheat is used as a filler and thickener in a number
of store bought and restaurant prepared foods.
Avoidance of gluten in the diet requires careful
scrutiny of food labels for the presence of wheat and
other offending grains such as rye, oats and barley.
Products labelled wheat-free are not necessarily
gluten-free. Common food items that can not be eaten
include breads, bagels, pastries, pasta and pizza.
There are companies throughout the United States which
produce gluten-free products made predominantly from
rice flour. Most patients treated with a gluten-free
diet will note a lessening of symptoms within 2 weeks
and no follow up intestinal biopsy is required. A
small group of patients have partial or no response to
a gluten-free diet. One important cause of a poor
dietary response is the continued ingestion of gluten
in foods thought to be gluten-free or just plain
dietary cheating. Antibody testing while such patients
are on a "strict" gluten-free diet may be
useful in this situation. A kit which utilizes the
Elisa assay has been developed to test food products
for the presence of the gluten antigen. In individuals
who have a poor response to a gluten-free diet, a
repeat intestinal biopsy is mandatory after 3 months
treatment to assure that other intestinal lesions such
as infection or intestinal lymphoma was not missed.
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Why treat celiac
disease?
In symptomatic patients
the obvious answer is to relieve debilitating
symptoms. What about individuals who have minimal
symptoms or who are asymptomatic? There are two
reasons to treat such individuals with a gluten-free
diet: 1) a subgroup of these patients will progress to
more severe disease and hence develop symptoms and 2)
there is an increased incidence of small intestinal
lymphomas and adenocarcinomas in individuals with
celiac disease. The increased incidence of cancer
seems to correlate with the degree of intestinal
inflammation (activity) present, as individuals whose
disease responded to a gluten-free diet and who
remained compliant with the diet had a lower incidence
of such cancers. Whether individuals who are found to
have elevated antibodies specific for celiac disease
but are asymptomatic and have normal intestinal
biopsies should be treated with a gluten-free diet is
unclear.
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