If you have celiac disease or gluten intolerance, even the smallest amounts of gluten are harmful to your health. Gluten is a protein found in some grains: wheat, rye, barley, spelt and khorasan wheat. In celiac disease, the immune system produces antibodies that attack the gluten in the small intestine. They cause chronic inflammation that destroys the delicate cells of the intestinal wall and the intestinal villi intestinales (the inner lining of the intestine). The disease can break out at any age. Roughly 5 to 10 in 1,000 Dutch people have celiac disease, the majority of whom are women. The disease is not fully expressed in all cases; some people barely notice any symptoms. Celiac disease, previously also called native thrush, indicates an intolerance to gluten. It is an autoimmune disease that should not be confused with a wheat allergy, an allergic reaction that is caused by IgE antibodies.
- What is celiac disease?
- Synonyms
- Symptoms of celiac disease
- Symptoms in adults
- Symptoms in young children
- Causes of celiac disease
- Genetic predisposition
- Autoimmune response
- Celiac disease hinders the body’s supply of nutrients
- Comorbidity
- Examination and diagnosis
- Treatment of celiac disease
- Gluten free diet
- How quickly does a gluten-free diet work?
- What is a gluten-free diet?
- Vaccine against celiac disease
- Course and prognosis
- Prevention
Endoscopy of the duodenum (duodenum) in a patient with celiac disease / Source: Unknown, Wikimedia Commons (CC BY-SA-3.0)
What is celiac disease?
Celiac disease is an autoimmune disease caused by gluten intolerance that mainly affects the small intestine. You are hypersensitive to gluten. Celiac disease is not an allergy. It is characterized in particular by a chronic inflammation of the lining of the small intestine due to hypersensitivity to gluten. These are proteins found in some grains. Other organs may also be affected. The intolerance remains lifelong, is partly hereditary and cannot be cured. The treatment of celiac disease consists of following a gluten-free diet.
Foods containing gluten cause inflammation of the lining of the small intestine, often with extensive destruction of the intestinal epithelial cells and villi intestinales. As a result, nutrients are poorly absorbed and remain largely undigested in the intestine. The symptoms and severity of the disease can vary greatly, making it difficult to recognize. Possible symptoms include (unintentional) weight loss, diarrhea, vomiting, loss of appetite, fatigue, depression, tendency to bleeding (due to a lack of clotting factors due to vitamin K deficiency) and growth retardation during childhood (slow physical development); neurological disorders can also occur.
Untreated celiac disease increases the risk of non-Hodgkin’s lymphoma (a cancer of the lymph nodes) and probably cancer of the digestive tract. Celiac disease is associated with diabetes mellitus type 1 in five to ten percent of patients. In 2023, the treatment of celiac disease consists exclusively of a gluten-free diet.
Synonyms
Celiac disease is or was also known as:
- gluten intolerance
- celiac disease
- celiac sprue
- gluten enteropathy
- gluten enteropathy
- gluten-sensitive or gluten-induced enteropathy
- intestinal infantilism (obsolete medical name)
- native thrush
- intestinal thrush
- celiac disease
- celiac
- morbus Gee-Herter-Heubner
- Herter’s infantilism
- Gee’s disease
- Gee-Herter disease
- Gee-Herter-Heubner disease
- Gee-Thaysen disease
Symptoms of celiac disease
Often there are several symptoms that can occur separately. Due to the large number of different forms, a quick diagnosis is often difficult. Depending on age, the following symptoms may occur:
Symptoms in adults
Adults with celiac disease may experience the following symptoms, among others:
- fatigue
- exhaustion
- anemia
- iron deficiency and other mineral and vitamin deficiencies (e.g. vitamin B12, vitamin D)
- weight loss
- diarrhea or constipation
- flatulence
- loss of appetite
- vomit
- stomach ache
Symptoms in young children
Young children with celiac disease may experience the following symptoms:
- diarrhea or strong smelling stools
- bloated stomach
- stomach ache
- weight loss
- growth stagnation or retardation
- delayed puberty
- pallor
- nausea
In older children and adolescents, symptoms are more similar to those in adults.
Causes of celiac disease
The exact cause of celiac disease is not yet known in 2023. Various factors play a role in the development of celiac disease. In order to become ill, at least two conditions must be met:
Genetic predisposition
A genetic predisposition, which occurs in 30 to 40 percent of the population, increases the risk of celiac disease by a factor of three. It concerns the presence of certain surface features on immune cells: the proteins HLA-DQ2 or HLA-DQ8. There is a familial predisposition to celiac disease. If a first-degree relative (siblings, parents, or children) has celiac disease, the family members are also at increased risk (about 10 to 15 percent) of having or developing celiac disease.
Autoimmune response
Gluten is not fully digested. Undigested fragments of the gluten molecules are absorbed by the lining of the small intestine and are wrongly recognized by the immune cells of people with HLA-DQ2 or HLA-DQ8 variation as an ‘enemy’, similar to a pathogen causing a bacterial or viral infection . The activation of the immune system is even more pronounced when the gluten fragments react with the body’s own enzyme tissue transglutaminase (tTG), which is found throughout the intestine. Defense substances, so-called antibodies, are therefore produced against this enzyme. Because these antibodies are directed against the body’s own tissue, this is called an autoimmune reaction or disease.
Other factors that may promote the development of celiac disease include early and massive contact with gluten in genetically predisposed children or intestinal infections.
Celiac disease hinders the body’s supply of nutrients
Normally, useful nutritional components pass through the intestinal mucosa into the small blood vessels and thus throughout the body. In order to obtain the largest possible surface area for effective absorption of nutrients, the wall of the small intestine is lined with many millions of small, hair-like projections: the so-called intestinal villi or villi intestinales. Intestinal villi are the flocculent appendages in the intestines, especially the small intestine. When these villi are destroyed, the surface area of the small intestine is reduced. Especially in children, the reduced functioning of the small intestine can lead to malnutrition and thus growth and development disorders. Due to the inadequate supply of nutrients, celiac disease is considered a systemic disease that affects the entire body. The inflammation continues as long as the person eats foods containing gluten. It decreases once the small intestine is no longer exposed to gluten.
Comorbidity
Celiac disease often occurs together with other diseases. This has to do with the underlying genetic composition. The presence of HLA-DQ2 and/or HLA-DQ8 on immune cells also promotes other autoimmune diseases. The continued consumption of gluten can increase the risk of autoimmune diseases that often occur in combination with celiac disease. The diseases that often accompany celiac disease include the following:
- diabetes mellitus type 1
- autoimmune thyroid diseases (Hashimoto’s disease, Graves’ disease)
- autoimmune diseases of the skin (dermatitis herpetiformis)
- autoimmune hepatitis
- primary biliary cirrhosis
- a certain type of hair loss (alopecia areata)
- psoriasis
- rheumatoid arthritis and other rheumatic diseases
Celiac disease is common with other genetic diseases (Down syndrome, Turner syndrome).
Blood test / Source: Alexander Raths/Shutterstock.com
Examination and diagnosis
If celiac disease is suspected, the blood can first be examined (blood test) for special autoantibodies. The diagnosis is ultimately confirmed by an endoscopic small bowel biopsy. The doctor inserts a flexible tube, the endoscope, through the mouth, esophagus and stomach into the small intestine and there is a camera at the tip of the tube. The doctor takes samples of the lining of the small intestine, which are examined microscopically. In this way it can be determined whether changes have occurred in the villi of the small intestine, which are typical of celiac disease. The examination is usually performed on an outpatient basis and usually only takes 10 to 15 minutes.
Treatment of celiac disease
Gluten free diet
The only way to treat celiac disease in 2023 is to follow a strict gluten-free diet, which the patient must adhere to for the rest of his life. In many cases, a gluten-free diet initially leads to quite a change, which usually takes place together with a nutritionist or dietician, also to avoid a one-sided diet. First a little more often, later every one to two years, a doctor will check up.
Even without gluten, a person can eat a balanced and varied diet to ensure they get adequate amounts of all the important nutrients. Therefore, nutritional supplements are only needed very rarely, possibly only in the first weeks or months of a gluten-free diet. If there are deficiencies, for example in iron, calcium, magnesium, vitamin B12, folic acid or vitamin D, the patient should supplement the missing nutrients for a few weeks or even longer through supplementation in consultation with the doctor and/or nutritionist.
Some people with celiac disease have limited digestion of fat and lactose and therefore have additional problems such as diarrhea or flatulence . You may need to temporarily avoid fat and certain dairy products until the intestinal lining has recovered from the gluten-free diet.
How quickly does a gluten-free diet work?
In about two-thirds of people with celiac disease, symptoms improve in about two weeks with a gluten-free diet. The changes in the intestinal mucosa usually disappear after a few months: the inflammation decreases and the villi, which are so important for the absorption of nutrients, develop again. The risk of complications and long-term consequences is normalized after a few years with a strict gluten-free diet. The risk of degeneration of the lining of the small intestine (intestinal lymphoma) in late-diagnosed celiac disease also decreases rapidly with a strict gluten-free diet.
Wheat / Source: Peter van der Sluijs, Wikimedia Commons (CC BY-SA-3.0)
What is a gluten-free diet?
Eating gluten-free means that no products containing gluten should be eaten. The protein gluten is found in the following types of grain:
- rye
- wheat, including spelt and khorosan wheat
- barley (barley, is peeled barley)
People with celiac disease should avoid these grains and products containing them. If a product is declared gluten-free on the packaging, gluten should not be included in an amount that could be harmful to celiac patients. The prescribed guideline value for gluten-free products is less than 3 ppm (Parts Per Million). Gluten-free include:
- corn
- rice
Buckwheat products / Source: Andrey Korzun, Wikimedia Commons (CC BY-SA-4.0)
- millet
- buckwheat
- soy
- Sesame seed
- potatoes
- Quinoa
- amaranth
Oats are naturally gluten-free, but are often contaminated with gluten during harvesting, transport, storage and processing, for example from wheat, barley and rye. Therefore, celiac patients should only use oats that have been declared gluten-free due to the production process.
Vaccine against celiac disease
In 2023, a vaccine against celiac disease is still in the future. Such a vaccine should train the immune system so that it responds ‘tolerantly’ to gluten. After vaccination, the tolerant immune system would no longer cause an immune response in people with celiac disease.
Course and prognosis
Celiac disease does not affect the life expectancy of those affected if they consistently follow a gluten-free diet. In most patients, the inflammatory processes in the small intestine subside within a few months and they are practically symptom-free. Only in a few cases are there so-called diet-resistant forms of celiac disease, which must be treated with immunosuppressants, that is, drugs that suppress the immune system.
Especially at the beginning of the diet change, when the lining of the small intestine is rebuilding, side effects and complications such as intestinal obstruction, diarrhea, loss of electrolytes and abdominal pain may occur, which can be treated well and disappear as the recovery process progresses.
Prevention
Celiac disease cannot be prevented. It makes no sense to give gluten to babies between the ages of 4 and 6 months and breastfeeding does not protect babies against celiac disease.