Celiac Disease or Gluten-Sensitive Enteropathy

Coeliac disease, also called gluten-sensitive enteropathy, is a disease of the small intestine characterized by intolerance to gluten, a protein present in many foods such as wheat, oats and barley.

Celiac disease
Celiac disease

What is gluten?

Gluten is a protein present in several cereals, especially wheat, oats, rye, malt, triticale, spelt or barley. This means that a multitude of foods made based on these products contain gluten in their formula, including cereals, breads, pastas, pizzas, cakes, candies, cookies, chips, cereal bar, breaded products, waffles, soups, croutons, fries , beer, whiskey and vodka distilled from grain.

You may have noticed that a large variety of foods have the warning "contains gluten" on their packages. This notice is intended for patients with celiac disease, who, as we shall see, cannot consume any food containing gluten.

What is celiac disease?

Celiac disease is a disease of immunological origin and is characterized by the occurrence of an intense inflammatory reaction in the small intestine every time it is exposed to foods containing gluten. In some cases inflammation may be so severe that destroys the villi of the small intestine mucosa, which are responsible for absorption of most nutrients. The result of this process of inflammation and damage of the intestinal mucosa is an intestinal malabsorption syndrome (syndrome is explained later).

Celiac disease is a disease of autoimmune origin and is different from gluten allergy. The immune mechanism is distinct from celiac disease, as well as its clinical picture.

Celiac disease is a relatively common disease and can affect anyone, but is most common in Caucasians (whites) descended from northern Europeans. In Europe and the U.S. about 1 in every 150 people has celiac disease. In the Nordic countries this rate is up to 1 in every 90 people. About 25 million people suffer from this disease worldwide.

Once considered a pediatric disease, we now know that gluten enteropathy can occur at any age. 60% of cases occur in adults, 20% in patients older than 60. In children, in general, the disease becomes apparent when they are still babies, after the first exposure to dietary gluten.

Most patients with celiac disease have a milder form of the disease with little or no symptoms, with years passing without even suspecting any problems. It is estimated that for every patient with typical symptoms of celiac disease there are other seven celiac silent or oligosymptomatic (with mild symptoms). Therefore, despite advances in diagnostic methods, the true prevalence of celiac disease may still be underestimated.

Risk factors for celiac disease

The gluten enteropathy has a strong hereditary component. About 10% of first degree relatives of a patient with celiac disease are also carriers of the disease.

New evidence indicates that the time and manner of first exposure to gluten can increase the risk of developing celiac disease. Observational studies suggest that the risk for gluten enteropathy may be reduced by the gradual introduction of gluten in the diet of the baby, preferably after the sixth month of life, and while the child is still under breastfeeding.

Celiac disease can occur in anyone, but some people with autoimmune diseases have a higher risk than the general population. They are:
Risk factors for celiac disease
Risk factors for celiac disease

Other autoimmune diseases of unknown origin are also related to a higher incidence of celiac disease, as:

Symptoms of celiac disease

Classic symptoms of celiac disease occur due to atrophy of the villi of the small intestine, which prevents the absorption of various nutrients, including fats, proteins and vitamins. The lack of absorption of food in the gut causes malabsorptive syndrome (or malabsorption syndrome), characterized by diarrhea (often with drops of fat in the stools, called steatorrhea), flatulence, abdominal cramps, weight loss and problems caused by deficiency vitamins and nutrients such as anemia from iron deficiency, folic acid and/or vitamin B12, osteopenia (weak bones) from lack of vitamin D and calcium, and bleeding from deficiency of vitamin K. In children, if the diagnosis is not made early enough, there is often malnutrition and delayed development and growth.

Non-gastrointestinal manifestations of celiac disease include:
  • Dermatitis herpetiformis (a skin lesion typical of gluten sensitive enteropathy)
  • IgA nephropathy
  • Changes of tooth enamel
  • Arthirtis
  • Delayed puberty
  • Menstrual disturbances
  • Migraine
  • Neurological disorders
  • Cramps
  • Liver alteration

The clinical picture of celiac disease varies greatly from patient to patient. Some may have many of the problems mentioned above while others feature an atypical form, with few or no symptoms of poor absorption of the intestine or other gastrointestinal symptoms. There is yet also a group which does not exhibit any symptoms of disease, called silent celiac disease.

The symptoms tend to improve with the elimination of gluten from the diet. About 70% of people begin to feel better within two weeks after withdrawal of gluten.

Diagnosis of celiac disease

Celiac disease can be difficult to diagnose because the signs and symptoms are similar to many other diseases that cause gastrointestinal symptoms and malabsorptive syndrome. Also, if the doctor is not very observant, lack of gastrointestinal symptoms in atypical forms will not help in differentiating celiac disease, so the examinations necessary for its diagnosis will not be carried out.

Over 90% of people with untreated celiac disease have elevated levels of certain antibodies in their blood, including antigliadin antibodies, endomysial and transglutaminase (anti-tTG), the latter being the most sensitive for the diagnosis.

Before performing these blood tests, it is important to consume a normal diet, including foods that contain gluten. Patients who are no longer eating gluten may have low levels of these antibodies, so the diagnosis becomes more complicated.

Antibody levels also serve to monitor the effectiveness of the diet and these should be low even if the patient is avoiding gluten.

If the blood test is positive, the diagnosis should be confirmed by biopsy of the intestinal mucosa, performed during an endoscopy. Again, the patient should not be doing gluten free diet so the lesions typical of celiac disease are present. Patients with positive antibodies and skin lesions suggestive of dermatitis herpetiformis can make the diagnosis by biopsy of these lesions because they are the manifestation of skin of celiac disease. In these cases intestinal biopsy may not be necessary.

Treatment of celiac disease

Gluten free diet
Gluten free diet
Celiac disease has no cure but can be controlled adequately. In general, medications are not necessary. The basis of treatment is only complete elimination of gluten from the diet. Maintaining a gluten-free diet is a challenging task that may require major adjustments in lifestyle of the patient. Gluten is not only present in a large amount of usual Western food, but also in some medicines and dietary supplements.

The assistance of a dietician is essential, since many foods that supposedly are not made from cereals may have hidden gluten in their composition, such as ice cream, yogurt, chocolates, sausages, salami, marinated and other products.

Once the patient has removed gluten from their diet, inflammation of the small intestine will begin to disappear within a few weeks, but the symptomatic improvement is more rapid, occurring within a few days of dieting. The complete resolution of the recovery and the villi of the intestine may take several months, or even years, depending on the severity. The improvement tends to occur more rapidly in children than in adults.

Gluten-free foods

Despite the large amount of foods that contain gluten, the options for a gluten free diet are also immense. Examples of foods that do not contain gluten and can be consumed by celiac disease patients: Fresh fruits, vegetables, meat, chicken, fish, pork, most dairy products, rice, corn, soy, potato, cassava, beans, amaranth, corn, gluten-free flours (rice, soy, corn, potatoes, beans), quinoa , tapioca and wine.

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