By: Charles A. Dasher, Jr., MD with
Birmingham Gastroenterology Assoc.
Gastrointestinal illness often has a marked impact on quality of life, and celiac disease (CD) in its more severe form is a great example of this. In its milder form you may not have any symptoms at all, but malabsorption of nutrients may be occurring. For example, impaired iron and vitamin absorption can occur and lead to anemia or altered clotting of the blood. However, most people with celiac disease come to clinical attention because of bothersome symptoms like diarrhea, weight loss, and crampy abdominal discomfort. CD can occur in people of any age and it affects both genders.
CD occurs when the immune system inappropriately responds to ingested gluten and leads to damage to the lining of the small intestine. It is not clear what causes CD, but it likely involves both environmental and genetic factors. In fact, in cases where the diagnosis may be uncertain, a simple blood test to look for a certain genetic component can be helpful. When that genetic make-up is absent, it essentially excludes the possibility of CD in that patient. Furthermore, CD is much more common in certain areas of the world than others-supporting both environmental and genetic predisposition as important in the development of the disease. Gluten-free diets (GFD) have become popular, trendy diets that many Americans try, but those with true CD understand that a GFD is more than just a fad. CD usually responds well to a GFD, but strict compliance is a must. Even small amounts of gluten that make their way into the diet can wreak havoc on a previously well controlled patient with the disease.
CD can be difficult to diagnose because the signs and symptoms are similar to other conditions. Fortunately, testing is available that can easily distinguish untreated CD from other conditions. Simple blood tests to evaluate for certain antibodies that become elevated in people with CD is often the first test ordered, and there should be a low threshold for ordering it in the right clinical scenario. Over 95% of those with CD will have elevated levels of these antibodies, while it is exceedingly uncommon for the levels to be elevated in those without the disease. If the blood test is positive or the diagnosis remains uncertain, a biopsy of the small intestine is usually required to confirm the diagnosis. The biopsy is easily collected via an upper endoscopy. In patients with CD, the lining of the small intestine may have some typical appearances; however, a normal appearing lining does not exclude CD. Biopsies must be taken for microscopic examination to look for the characteristic findings. Normally, the lining of the small intestine has distinct finger-like projections called villi that allow the intestine to absorb nutrients. In CD, small intestine biopsies characteristically show flattening of the villi, among other changes. Fortunately, once gluten is removed from the diet, the villi resume a normal growth pattern and most patients begin to feel better within two weeks after eliminating gluten from the diet.
Complications from CD can occur, but the risk is substantially lowered by long-term compliance with a GFD. When individuals fail to respond to a GFD, a search for other co-existent conditions should take place, including small intestinal bacterial overgrowth, microscopic colitis, and irritable bowel syndrome. Usually, inadvertent ingestion of gluten is to blame for failure to respond to a GFD. Thus, early consultation with an experienced dietician is an invaluable tool to minimize the chance of this happening. Certain types of lymphoma have been associated with celiac disease, but the risk is low and minimized further by long-term compliance with a GFD.
As mentioned before, the treatment of CD is removing ALL gluten from the diet. Steroids may be needed in the rare cases of refractory celiac disease, but long-term side effects from steroids are often worse than complications from incompletely treated CD. Steroids should never be used as first line therapy for CD. Although changing a diet may seem better than taking medications, following a GFD is challenging and requires major lifestyle adjustments. On the positive side, most patients with CD have complete resolution of their symptoms with strict GFD. There aren’t many medical conditions that have such good outcomes from dietary modification alone, and many are glad to learn they don’t need another medication added to their daily regimen!
General Tips to Remember about CD:
• If signs and symptoms of CD are present, testing should be done
• Avoid gluten-containing foods such as wheat, barley, malt, brewer’s yeast, and oats (unless pure and uncontaminated foods with gluten-free label)
• Naturally gluten-free foods include rice, corn, potato, soy, many beans. However, watch out for gluten contamination of these foods when purchased processed or prepared
• Early involvement of an experienced dietician is an important part of CD management