How to treate Celiac Disease ?

What are the risks?

Until recently it was believed that celiac disease affects only 1 in every 1,500 people. Today we know that more often. A correct diagnosis based on simple blood tests revealed that the disorder affects 1 in 300 people in Europe and the United States. The disease is more common in certain areas of the world, including the west coast of Ireland, where it is considered that 1 in 100 people have celiac disease.

Thus, celiac disease is a common disorder that can occur at any age. Although once thought it was more frequent in males, now thought to affect both sexes equally.

Sometimes celiac disease is associated with other processes. People with insulin-dependent diabetes (type 1), abnormal thyroid or ulcerative colitis associated with increased risk of celiac disease.

What is the cause of celiac disease?

When gluten (found in wheat, rye and barley) comes into contact with the lining of the small intestine is a reaction by which the immune system mistakenly attacks the lining as if it were an external aggressor. The mucosa of the small intestine has villi, small finger-like projections that are observable only under the microscope. These villi allow for a greater surface than that would be if the plane intestine; through that surface are absorbed nutrients such as vitamins, iron and calcium . In celiac disease, these villi are attacked by the immune system, causing progressive atrophy and finally its disappearance. The consequence is that the nutrients in food pass through the intestine without being absorbed, causing vitamin and mineral deficiencies, anemia and weak bones ( osteoporosis ).

A real risk occurs celiac disease is a family history of the disease. Coeliac disease in genetically predisposed appears, ie has a familial incidence. If you have a parent, sibling or child with celiac disease, has a 10% chance of developing the disease. If you have an identical twin with celiac disease, your chances of developing the disease above 70%.

What are the symptoms?

Celiac disease has many and varied symptoms, different in adults than in children.

In childhood symptoms do not appear until introduced into the diet foods containing gluten. Initial symptoms consist of irritability and restlessness, loss of appetite and difficulty gaining weight. The stools may become clear, copious and very smelly. In some children the symptoms are vomiting and diarrhea, so they are often misdiagnosed a “gastroenteritis”. The abdomen may become distended while arms and legs lose much muscle mass.

In adults the symptoms may be similar, including weight loss and diarrhea, loose stools, smelly or, conversely, constipation, bloating, flatulence and bloating with. Half of adults with celiac disease and intestinal symptoms seek medical treatment for exhaustion, psychological disorders (depression), bone pain or fractures (due to the weakening of the bones), mouth sores or a rash (blistering and itching) located primarily on elbows and knees and is known as dermatitis herpetiformis .

Some women with celiac disease have difficulty getting pregnant, and this may be the clue that leads to the diagnosis. Spontaneous abortions are repeat sometimes in association with celiac disease. Some women are diagnosed during pregnancy because their intestine can not absorb enough iron and vitamins to meet the increased demands of pregnancy, so they develop severe anemia. Women with celiac disease are more frequently underweight babies (for intrauterine growth retardation due to poor nutrition).

There are other rare diseases that can be detected in the population, but they appear more frequently in people with celiac disease. Typically, these disorders are the subject of a clinical study conducted by a specialist who works in a hospital. These include autoimmune diseases (because the immune system attacks the body unexpectedly), whether the thyroid, insulin-dependent diabetes mellitus or a disease that affects the liver and is known as primary biliary cirrhosis .

In a neurological clinic, dedicated to the study of brain diseases and the rest of the nervous system, we studied a series of patients who had abnormal gait and coordination of movements (ataxia), conducting tests to detect blood in the antibodies suggestive of celiac disease. A significant proportion of these patients was found to be affected by celiac disease, although many of them had never had intestinal symptoms.

How is celiac disease diagnosed?

By making medical history, your doctor will ask about your symptoms. Will be interested in the frequency of bowel movements and appearance, consistency and color of the stool. You’ll also want to know if you have lost weight or if you have symptoms of anemia (tiredness, fatigue , pallor). Your doctor may explore the abdomen or be fixed in the possible existence of a bullous eruption of the skin or mouth ulcers.

Initial studies typically involve analysis of blood. The doctor will try to detect the presence of anemia and iron blood determinations request, folic acid and calcium, among others. There are other blood tests aimed at identifying antibodies (immune system components) that are detected frequently, but not always, in celiac disease. Among this group of antibodies associated with celiac disease, the more specific the endomysial antibody, directed against an enzyme called tissue transglutaminase. If these antibodies are detected in the blood, is very likely to suffer from celiac disease.

However, a definite diagnosis requires the study of intestinal tissue piece obtained through a microscope of one intestinal biopsy . This procedure is usually performed in a hospital, usually in the Department of Gastroenterology or Endoscopy Unit. Access to the first portions of the intestine by endoscopy : general anesthesia or, if you prefer, with local anesthesia of the throat, an endoscope is inserted through the esophagus and stomach into the duodenum, once there, the endoscopist can directly visualize the intestinal mucosa and take a small piece for analysis. The patient does not have to suffer discomfort special and the procedure takes about 10 minutes. Sometimes it is necessary to use an intestinal biopsy capsule, the method is more complex but also safe. In any case, the biopsy obtained is sent to the laboratory where they studied microscopically to assess the number and morphology of the villi. This procedure usually confirm the diagnosis. It is usually recommended to repeat this procedure after several months of gluten free diet to confirm the normalization of the intestinal lining.

What else could it be?

The diarrhea and weight loss may be due to various causes. One of them is an intestinal infection caused by parasites such as the type of Giardia lamblia and Strongyloides. If symptoms began after a holiday in a tropical country, one of these infections may be the cause. Other rare causes of malabsorption are an overgrowth of bacteria in the intestinal flora in the small intestine, the lactose intolerance , Whipple’s disease or intestinal lymphoma.

What treatment is available?

Some good advice:

Although celiac disease is preventable, adoption of a gluten-free diet can reverse bowel injury. This requires great discipline. Gluten is present in the bread, buns, cakes and sweets, pastas, cereals and in some soups and sauces. There are also gluten “hidden” in some foods such as breakfast cereals, diet bars, potato chips, bark of wheat and other products of its kind to be offered as snacks in bars and restaurants. Certain cooking oils, especially mixtures of vegetable oils, may contain wheat germ oil, so it is best to use olive oil or alternatively sunflower. Soy sauce, mustard and mayonnaise commercial gluten. Beer, whiskey and bourbon is made from cereals containing gluten, but other alcoholic beverages such as wine and cider, are free from this substance.

Of course, there are many foods that do not contain gluten, like all fruits, salads and vegetables, rice, corn, nuts, potatoes, red meat, chicken and other poultry, fish, eggs and dairy.

It is prudent to avoid oats, which may contain small amounts of gluten. Generally this does not worsen in patients with celiac disease, but it is very common that the same is stored in barns than wheat, so it is easy to be contaminated with gluten.

There are excellent books on gluten sensitivity, including general guides and cookbooks.

Some medications contain gluten, so you should read the prospectus and consult your doctor or pharmacist if in doubt.

What can your doctor do?

The gluten-free foods are available with or without a prescription. There you flours, breads, cakes and pasta gluten-free can be used as substitutes for normal foods containing gluten. Your GP may refer you to a dietary service, where you can get advice and food lists.

Another important aspect of treatment is adequate intake of vitamins and minerals. You may need to take iron tablets, folic acid supplements (especially if you are pregnant or planning to become pregnant) and calcium.

The most severe forms of celiac disease, who do not improve with the gluten-free diet, may require treatment with drugs that modulate the immune system, such as glucocorticoids, but this event is very rare.

The treatment is free of serious risks. However, the gluten-free diet is usually low in fiber, so that some patients develop constipation. To avoid this problem it is advisable to eat fruits and vegetables in abundance. If it persists, try rice bran or a laxative based Plantago ovata (there are several brand names that you can get at your pharmacy or without prescription).

What consequences does not make treatment?

If you do not follow a gluten-free diet, the symptoms persist, including diarrhea, anemia and weight loss.

What is the most likely evolution?

Complications of celiac disease are rare. These include infertility in women, complications during pregnancy, autoimmune diseases (thyroid gland, diabetes and liver diseases such as primary biliary cirrhosis), weak bones (osteoporosis). There is a slightly increased risk of suffering in the gut a type of cancer called lymphoma process. However, tracking a gluten-free diet reduces the incidence of these complications and related disorders such as dermatitis herpetiformis or ulcers of the mouth (thrush).

Studies have shown that following a gluten free diet for five or more years reduces the risk of all cancers associated with celiac disease at the population level in general.

In most patients the gluten free diet leads to normalization of the skin (epithelium) of the intestine. Thus, the disease can be “cured”, but only by avoiding foods that contain gluten. If you have it, keep in mind that you can have a good quality of life, symptom-free and long-term complications.

Dr. Jocelyn S. Fraser , a specialist in Gastroenterology