Cause and Effect

Celiac disease is caused by an inflammatory response in the lining of the small intestine that results from the exposure to ingested gluten. The mucosal damage affects the “finger of like” projections” of the small intestine (villi). In other words food is not transported across the small intestine into the body and a “wasting disease” can occur with variable manifestation (subtotal villous atrophy) resulting in their “blunting” and this affects the ability of the small intestine to absorb food (nutrients). Therefore, varying degrees of malnutrition occur due to malabsorption of nutrients (mal=poor or bad).

Gluten is composed of a group of proteins that are found in many different types of grains (wheat, barley, triticale, kamut, rye and spelt). Gluten can also be present in oats, often as a contaminant from mixed grain processing. That said, gluten is ubiquitous in the food chain because it is often used as a “thickening agent” in processed foods, a filler in pills or supplements and it is present in some cosmetics. Gluten is a popular ingredient in Chinese food. In brief, gluten is widespread in its occurrence in the diet and but it is often “occult” (hidden).
Gluten is partially digested by an individual with celiac disease, resulting in a protein called gliadin. The alpha-gliadin fraction of gluten seems to be the miscreant in triggering the damage to the villi of the small intestine. There is a genetic tendency to gluten sensitivity which occurs most often in individuals of Northern European Origin (especially Celtic people, Scots and Irish). While inflammation occurs, celiac disease is associated sometimes with autoimmune disorders (attack against the body’s own tissues by the immune system). Thus, celiac disease can sometimes go hand in hand with Type I diabetes, thyroid gland hyperactivity or insufficiency, systemic lupus erthematosis (SLE) and rheumatoid disease.

The Clinical Picture
Celiac disease is regarded as the classic disorder of malabsorption. In its full blown state is causes diarrhea, foul-smelling copious stools, gas, bloating and abdominal pain. That said, many cases of celiac disease are quite silent or result in vague digestive upset with variable nutrient deficiencies such as: low iron levels in the blood (poor iron absorption disorder causing anemia), folic acid, Vitamin B12 deficiency, inadequate calcium absorption…to name a few.

The list of potential disabilities in celiac disease is very long (and often subtle). Celiac disease can cause failure to thrive in children (growth stunting), psychological problems (depression, anxiety, irritability), muscle cramping, loss of energy, peripheral neuropathy, tooth decay and skin rashes (one characteristic form of rash is intensely itchy raised lesions, often found on the elbows and knees and called Dermatitis herpetiformis). In recent times scientists have started to link gluten sensitivity with other disorders, especially behavioral problems in children (autism and Attention Deficit Hyperactivity Disorder, ADHD).

For many reasons, celiac disease may be a missed diagnosis or subject to misdiagnosis of other gastrointestinal problems or general medical problems. For example, damage to the small bowel makes the individual lactose intolerant (a deficiency of the enzyme lactose that is necessary to digest the milk sugar lactose). Some individuals who think they have simple lactose intolerance may have underlying celiac disease. Celiac disease can sometimes be associated with very serious disease, e.g. bowel lymphoma.

Diagnosis and Treatment
Diagnosis may be apparent with the use of special antibody testing on blood samples, but the definitive test is to biopsy the small bowel and examine the tissue for lost villi (subtotal villous atrophy). The lesion in celiac disease can be “patchy” and diagnosis is sometimes clouded. The most accurate test involves multiple small bowel biopsies.
The effective treatment of celiac disease is clear. The meticulous avoidance of gluten in the diet results in healing of the small bowel lesions (to a variable degree, over time). This dietary exclusion of gluten must be life long (the disease does not go away). Reintroduction of gluten into the diet of an individual with celiac disease causes relapse of symptoms.

Long Term Implications
Many studies show people who do not treat their celiac disease increases the risk for lymphoma (especially Non-Hodgkin types), adenocarcinoma of the small intestine and neurological disorders. Young women with celiac disease who are not effectively treated have a higher risk of spontaneous abortion (miscarriage) and an increased risk of birth defects (neural tube problems such as spina bifida, often related to folic acid deficiency).

The occurrence of gluten sensitivity is a major public health concern and much controversy exists concerning its estimated occurrence. On average, about one in three thousand people in the US are diagnosed with gluten sensitivity, but it has been proposed that its prevalence may be as high as about one in one hundred and thirty people. For many years, celiac disease was a “forgotten diagnosis”, but modern research underscores the importance of aggressive gluten exclusion in the individual with celiac disease.

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