News: Against the Grain: Finding Silent Celiac Disease

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Against the Grain: Finding Silent Celiac Disease

Haran

Until recently, celiac disease has been considered a children's

disorder marked only by gastrointestinal (GI) problems. But more and

more adults, including those without GI problems, are being diagnosed

with this autoimmune disorder, which is trigged by eating wheat, rye

and barley. An understanding of the links between celiac disease, also

known as celiac sprue, and associated conditions, such as osteoporosis,

is helping doctors identify more people with celiac disease.

Worked-up by Wheat

In people who are genetically susceptible to this disorder, celiac

disease is triggered by a protein component in wheat called gluten.

Similar proteins in rye and barley can also set off celiac disease in

this group of people.

" Basically, there is an immune response to the gluten proteins, which

eventually leads to inflammation and damage to the villi in the small

intestine, " explains Armin Adaedini, PhD, an assistant professor of

neuroscience at Weill Cornell Medical College of Cornell University.

Millions of these finger-like villi line the small intestine and play

an important role in absorbing nutrients in food.

It's not exactly clear how the wheat gluten, which never gets fully

digested in anyone, enters the lining of the small intestine, provoking

the reaction. It may occur when someone has a gastrointestinal

infection; GI infections have been found to increase risk of the

development of celiac disease in children. (Breastfeeding, however, has

been found to protect children from celiac disease.) Once the immune

system reacts to the gluten in the gut lining, it produces antibodies

that mistakenly attack the lining of the small intestines, contributing

to inflammation and the wearing away of the villi.

Not everyone who reacts to wheat has celiac disease, however. People

with irritable bowel syndrome, who may have trouble tolerating a lot of

grains, may have similar symptoms. And celiac disease should not be

confused with a wheat allergy, which will produce allergic reactions

that can range from hives and a rash to life-threatening anaphylactic

shock.

When Should You Suspect Celiac Disease?

In adults and children, the villi damage caused by celiac disease can

lead to symptoms such as abdominal pain, diarrhea, pale, foul-smelling

stool, weight loss and weakness. Some people may develop an itchy,

blistering rash called dermatitis herpetiformis. And irritability and

depression may be seen in people with celiac disease. One reason the

celiac disease diagnosis is challenging, however, is that the vague GI

symptoms can also be caused by a number of other intestinal conditions,

including irritable bowel syndrome, gastric ulcers and Crohn's disease.

Celiac disease can also lead to long-term problems. Because the small

intestines are no longer able to absorb needed nutrients from food,

over time people can suffer from vitamin and mineral deficiencies. And

in children, malabsorption can lead to growth problems.

The one thing about celiac disease that is clear is that it affects

people to varying degrees.

" Some people can be critically ill with severe malabsorption, and

others can be completely well, " says Green, MD, director of the

Celiac Disease Center at Columbia University. " So there's an enormous

spectrum, and we don't know why one person can nearly die and another

person is without symptoms. "

Today, more and more people who do not have the " classic " GI symptoms

of celiac disease are being diagnosed because they have conditions that

arise from nutrient deficiencies. For example, if you don't absorb

iron, you may develop anemia, and if you're not absorbing calcium, you

might develop the bone thinning disease osteoporosis.

New research confirms that people with osteoporosis are at very high

risk for celiac disease and vice versa. A study published in February

in the Archives of Internal Medicine found that all patients with

osteoporosis should be screened for celiac disease, though the

editorial suggested that more research is needed. In the study of 840

people, 12 of 266 participants with osteoporosis and 6 of the 574

people without the disease had celiac disease. In other words, celiac

disease occurred in 3.4 percent of people with osteoporosis versus 0.2

percent of people without osteoporosis.

Other people who are now considered at high risk for celiac disease are

those with other associated disorders, including hormonal diseases such

type 1 diabetes, thyroid disease and some reproductive disorders in

women. The connection between celiac disease and these conditions is

not well understood, but there may be a genetic link. Certain

neurological conditions, such epilepsy, migraine headaches and

peripheral neuropathy, which causes tingling in the hands and feet, are

also associated with celiac disease for unknown reasons.

Likewise, certain cancers are also somehow linked to celiac disease.

For example, people with celiac disease are at increased risk for

non-Hodgkin's lymphoma, small-intestine adenocarcinoma and esophageal

cancer. A gluten-free diet seems to protect people with celiac disease

from these cancers.

Another group at high risk for celiac disease is the first-degree

relatives of people with celiac disease. According to National

Digestive Diseases Information Clearinghouse, you have a 10 percent

chance of having celiac disease if someone if your immediate family has

it.

Celiac disease is thought to be most common in Caucasian people, and

people of Asian or African origin are considered to be at a lower risk.

But Dr. Adaedini observed that celiac disease needs to be studied more

carefully in these populations.

Delving into Diagnosis

To detect celiac disease, doctors give a blood test that looks for

anti-transglutaminase antibodies or anti-endometrial antibodies, which

people with celiac disease produce as part of their autoimmune response

to the wheat gluten protein. If the test is positive—or if the test is

negative but your symptoms strongly suggest celiac disease—you should

undergo an intestinal biopsy, in which a piece of the intestine is

removed and studied under the microscope to look for signs of celiac

disease-related damage.

But a diagnosis of celiac disease is not final until someone responds

well to a gluten-free diet, which reverses villi damage; the diet is

currently the only way to treat celiac disease, though some people may

go on steroids to reduce inflammation if diet by itself does not

improve symptoms. In some cases, people will try a gluten-free diet

instead of undergoing an intestinal biopsy. If you go on a gluten-free

diet and symptoms subside with 6 to 12 months, you probably have celiac

disease.

Getting on the Gluten-free Diet

The gluten-free diet involves avoiding anything that contains wheat,

rye or barley, so that includes many pastas, grains and cereals. To

obtain carbohydrates, people with celiac disease might substitute with

rice, quinoa, corn, buckwheat and potatoes.

Dr. Adaedini warns that wheat gluten may lurk in many foods you would

not expect to contain it, such as some salad dressings, yogurt drinks,

soy sauces, certain medications, mouthwash and processed foods.

It's not easy to stick with a gluten-free diet, but a dietician can

help you plan your meals so that you get relief from most of your

symptoms.

" A lot of the problems that are directly related to the damage to the

intestine go away, " Dr. Adaedini says, " but, currently, it doesn't seem

that a gluten-free diet has a big effect on some of the other problems,

such as the neurological symptoms, or the associated autoimmune

disorders. "

Still, if you are suffering from GI discomfort or have an associated

condition, getting tested for celiac disease might help your body get

the nutrition it needs—and help restore your health.

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