Celiac Disease

Introduction

If food is our source of energy, what happens when our bodies cannot absorb it properly? The small intestines are responsible for absorption of the proper nutrients our bodies need for survival. When our small intestines are damaged, this absorption does not occur properly. This is what happens in people who have celiac disease.

What is it?

Celiac disease is a chronic condition where the body reacts to a protein called gluten and loses its ability to absorb necessary nutrients. Gluten is most commonly found in wheat, barley, rye, and oats, but can also found in small amounts in less thought-of places, like stamp and envelope adhesive, medicines, and vitamins. Celiac disease is considered an immune disorder because with consumption of gluten, the immune system actually attacks the body's own cells in the small intestine.

The small intestines are responsible for proper absorption of nutrients needed for energy and building of body tissues. Tiny projections, called villa, line the small intestines to allow greater absorption of food and nutrients. A protein called gluten seems to trigger the immunological reaction of celiac disease. When a person with celiac disease eats a gluten-containing product, a reaction occurs and the body attacks the villa, leaving small lesions. Upon damage to the villa, the small intestine is then unable to absorb nutrients properly leading to symptoms of malnourishment, which if left untreated can be serious and life-threatening.

What causes it?

The exact cause of celiac disease is unknown. Research has shown that it may have a genetic link. Experts believe the disease is actually associated with a group of genes located on chromosome 6 that regulate the body's immune response to gluten proteins.

The disease sometimes emerges after some sort of distress to the body such as pregnancy, childbirth, illness, severe emotional stress, physical injury, or surgery.

Who has it?

Celiac disease is estimated to affect about 1% or over 3 million people in the United States according to the Celiac Disease Center from the University of Chicago. However, many cases go undiagnosed due to the lack of symptoms, vagueness of symptoms, and the rarity of this disease yields many doctors to look elsewhere for answers first. Celiac disease seems to affect people of European decent more commonly than others and can appear at any stage of life, from introduction of cereal into an infant's diet up to adulthood.

What are the risk factors?

  • Family History -Since celiac disease is a genetic disorder, having first-degree relatives with celiac disease increases the risk of developing this disease. Approximately 5-15% of people with siblings or parents who have celiac disease will also develop it and in 70% of identical twin pairs, both twins have the disease.

  • European decent -It has been discovered that the highest rates of celiac disease are found in Western Europe and in areas where Europeans have emigrated including North America and Australia.

  • Previously diagnosed autoimmune disorders -Celiac disease is an immune disease and any previous autoimmune disease such as lupus, rheumatoid arthritis, or autoimmune thyroid disease has been found to increase the risk of acquiring celiac disease by almost 25%.

What are the symptoms?

Celiac disease affects everyone differently. Some people report no symptoms at all. Others have a wide range of symptoms, varying from mild to very severe. Symptoms can also differ according to age.

General signs and symptoms of celiac disease:

  • Fatigue
  • Chronic diarrhea
  • Weight loss
  • Fatty stool (pale colored, foul-smelling, floating stool)
  • Abdominal (stomach) pain
  • Osteoporosis/bone loss
  • Joint pain
  • Depression
  • Irritability
  • Hair loss
  • Dermatitis herpetiformis (intensely itchy and blistery skin, especially on knees, elbows, and buttocks)

Symptoms specifically seen in infants:

  • Decreased growth
  • Decreased weight gain
  • Diarrhea

Symptoms specifically seen in young children:

  • Abdominal (stomach) pain
  • Nausea
  • Decreased appetite
  • Mouth sores
  • Rash
  • Irritability
  • Increased dependence upon parents

Symptoms specifically seen in teenagers:

  • Late puberty
  • Shortened puberty

Symptoms of malnutrition (such as anemia, delayed growth, and weight loss) or specific vitamin deficiencies may also appear, even in those without symptoms of celiac disease. Vitamins and minerals including iron, folic acid, Vitamin B12, Vitamin K, Vitamin A, Vitamin D, calcium, magnesium, and other B vitamins are examples of vitamin deficiencies. Some symptoms from these deficiencies that appear may include muscle cramps (low calcium, potassium), bone or joint pain (low vitamin D, calcium), skin problems (low vitamin A), weakness, fatigue (low iron, potassium, B vitamins), and abnormal blood results (low vitamin K, folate, iron, vitamin B12).

How is it treated?

The American Dietetic Association has identified six elements of treatment for celiac disease following diagnosis. They correspond with the word, CELIAC:

  • C: Consultation with a skilled registered dietitian
  • E: Education about the disease
  • L: Lifelong adherence to a gluten-free diet
  • I: Identification and treatment of nutritional deficiencies
  • A: Access to an advocacy group
  • C: Continuous long-term follow-up.

Unfortunately, drug treatments are lacking for celiac disease. Since gluten aggravates the condition, the main focus of therapy is to avoid gluten.

So, where is gluten found? Gluten is mostly found in wheat, barley, rye, and oats. It can also be found in certain adhesives, cosmetics, and medicines. Wheat is used widely by the food industry as a thickener in products like ice cream, pasta, sausages, breaded fish and meats, cheese spreads, salad dressings, soups, sauces, mixed seasonings, and many others. All beers contain gluten and should be avoided. Also, use caution when using gluten-free products as many of them are manufactured in the same machines as are gluten-rich products and may become contaminated. Some products may include modified starch, which contain gluten in the ingredients. If the food label lists modified starch, oats, barley, or wheat the item should be avoided. Determining which foods do not contain any gluten can be difficult. A dietician can help determine which foods are safe in patients with celiac disease.

Retailers are starting to become more aware of the need for gluten-free foods. Some restaurants are offering gluten-free menus. Some companies are listing gluten content on the packages of their food products. Wal-Mart's brand "Great Value" is one of them. Whole Foods Market is also offering baked goods without gluten from their "Gluten-Free Bakehouse." The number of gluten free products has increased greatly over the past few years. Many websites exist that compile information on the gluten content of popular foods and can help aid in your diet choices.

There is no standard to what is considered gluten-free however. Each company sets its own standards, but no federal standard exists. The FDA will not have to develop a standard until 2008 under the Food Allergen Labeling and Consumer Protection Act.

Besides avoiding foods that contain gluten, an individual with celiac disease also needs to avoid medications that contain gluten. Some pharmaceutical companies do provide gluten free medications; however, most pharmaceutical manufacturers cannot absolutely guarantee that their drug products are 100% gluten free as their suppliers may change inactive ingredients (of which gluten can be contained). If you would like to determine the gluten content of a medication, it is best to ask your pharmacist or contact the specific manufacturer of the drug. If the manufacture is not listed on the medication bottle, talk with your pharmacist for information on how to contact the manufacturer.

Here is a brief listing of pharmaceutical company phone numbers:

Abbott products 1-800-633-9111

GlaxoSmithKline products 1-888-825-5249

Pfizer products 1-800-438-1985

Teva generic drug products 1-800-545-8800

Wyeth products 1-800-338-2872

Avoidance of gluten should result in improvements of celiac disease symptoms within 48 hours, although it may take weeks to months for full recovery from symptoms. If symptoms continue after gluten has been removed from the diet, either the diet has had traces of gluten or another disease may be the cause of damage to the small intestines.

The symptoms of celiac disease can be treated to bring comfort to the patient. Anti-diarrheal medication can be used for treatment of immediate diarrhea symptoms until celiac disease is under control. Anti-diarrheal medications are not generally recommended for long-term use. Supplements may be needed to relieve symptoms of vitamin and mineral deficiencies as determined by a physician.

For severe cases of celiac disease, glucocorticoids can be tried on a short-term basis. However, when glucocorticoid therapy is stopped symptoms generally return. Therefore glucocorticoids are not routinely recommended. Gluten avoidance is still the best way to avoid flare-ups of celiac disease.

Helping Yourself

This disease can seem very overwhelming at times and even lead to feelings of depression or sadness because of the limits on what and where someone with the disease can eat. Since dining out and eating are such a big part of our society, this disease can take a toll on an individual's emotions as well as the physical effects. Don't let this disease get you down or keep you at home for fear of the effects of eating out. There are plenty of support groups and self-help resources available to help you make smart decisions about diet without having to sacrifice social activities.

  • Join a support group: Talking with others can be reassuring; there are several groups available through the Internet or ask your doctor for help.

  • Don't be afraid to eat out: Select places that specialize in the foods you can eat; become a repeat customer so the staff gets to know you and your special needs; and share your information with others so they to can enjoy the dining experience.

  • Seek help from a registered dietician: A dietician will teach you how to read food labels, adjust recipes, and seek information from food manufacturers.

What is on the horizon?

There are no medications on the market to cure celiac disease today. Current treatment is limited to maintaining a gluten-free diet. An experimental drug, called AT1001, was recently studied to determine its safety, tolerability, and efficacy in patients with celiac disease. No adverse effects were found in the study group that took the experimental drug, AT1001. Now, there are studies to determine the effectiveness of this drug in patients with celiac disease that should be completed over the summer of 2008. The drug, AT1001, competes with the signaling protein "zonulin", which may have an important potential role in the treatment of autoimmune diseases such as celiac disease.

Another experimental drug, CCX282-B is also currently being studied to determine its safety and effectiveness in reducing the harmful effects of gluten ingestion in patients with celiac disease.

Research is also being conducted to determine whether certain blood tests can diagnose celiac disease. Since celiac disease is an autoimmune disease, the presence of certain immune system components called antibodies, can determine whether a reaction against gluten will occur. Studies are now trying to determine whether this is accurate enough to lead to a diagnosis of celiac disease. If this does prove to be accurate enough, this would mean less invasive procedures for diagnosing celiac disease. One of the standards of diagnosing right now includes an endoscopy of the intestines and biopsy of tissue taken from there. An endoscopy involves the doctor using a small, flexible, lighted tube to view the intestines. The tube is easily passed through the mouth, esophagus, stomach, and into the small intestine to allow the doctor to view pictures of the digestive tract on camera.

Researchers are also trying to discover why certain people develop sensitivities to gluten when others do not. Researchers are looking to find a relationship between gluten exposure, celiac disease and other autoimmune diseases such as lupus, certain cancers and diabetes in order to help find better treatments and possibly one day a cure.

References

Mayo Foundation for Medical Education and Research. Celiac Disease. Available at: www.mayoclinic.com: Accessed February 2007 and February 2008.

Celiac Disease Foundation: Celiac Disease. Available at: www.celiac.org. Accessed: February 2007 and February 2008.

National Digestive Diseases Information Clearinghouse: Celiac Disease. Available at: www.digestive.niddk.nih.gov. Accessed: February 2007 and February 2008.

Celiac Sprue and Refractory Sprue. Gastrointestinal and Liver Disease Pathology/Diagnosis/Management Volume 2. 7th ed. Feldman M, Friedman L, Sleisenger M, Philadelphia: Sauders; 2004:1817-1838.

The Wall Street Journal Online: Choices Grow for Wheat-Free Diets. Available at: http://www.medicinenet.com/celiac_disease/article.htm. Accessed: November 1, 2005 and February 2008.

Swerlick RA, Lawley TJ. Disorders of the Gastrointestinal System. Harrison's Principles of Internal Medicine. 16th ed. Kasper DL, Fauci AS, Longo, DL, eds. New York: McGraw-Hill;2000:1770-1773.

Celiac Disease Foundation. Annual Meeting Recap. Available at: http://www.celiac.org/newsletters/2001-04-mtg-recap.php. Accessed: November 7, 2005.

Marcus, Mary. Celiac Disease: It?s Common, and commonly misdiagnosed. USA Today 2006, Available at: http://www. usatoday.com/news/health/2006-11-01-celiac_x.html. Accessed February 2007.

Celiac Disease Awareness Campaign. National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health, and the National Digestive Disease Information Clearinghouse. Available at: http://www.celiac.nih.gov/. Accessed February 2007 and February 2008.

Celiac Disease and Gluten-Free Diet Information. Available at: http://www.celiac.com/index.html. Accessed February 2008.

Celiac Disease. National Digestive Diseases Information Clearinghouse. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/index.htm. Accessed February 2007 and February 2008.

Celiac Sprue Association. Available at: http://www.csaceliacs.org/gluten_grains.php. Accessed February 2007 and February 2008.

Dietetics Professionals Key to Managing Celiac Disease, 2004. American Dietetic Association. Available at: http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/home_3982_ENU_HTML.htm. Accessed February 2007 and February 2008.

American Celiac Disease Alliance. Available at: http://www.americanceliac.org. Accessed February 2007. University of Chicago Celiac Disease Center. Available at http://www.celiacdisease.net. Accessed February 2008.

Clinicaltrials.gov. Phase IIb Study to Study the Efficacy of AT-1001 to Treat Celiac Disease. Available from: http://clinicaltrials.gov/ct2/show/NCT00492960?intr=%22AT-1001%22&rank=4. Accessed February 2008.

Clinicaltrials.gov. A Phase II Study of CCx282-B in Patients with Celiac Disease. Available from: http://clinicaltrials.gov/ct2/show/NCT00540657?term=celiac+disease&rank=4. Accessed February 2008.

Clinicaltrials.gov Can a Very High Result from a Screening Test for Celiac Disease be Used to Diagnose Celiac Disease? http://clinicaltrials.gov/ct2/show/NCT00175760?term=celiac+disease&rank=1. Accessed February 2008.

Celiac Disease Health Condition Last Updated: February 2008

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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