Celiac Disease

BASICS

DESCRIPTION

A chronic diarrheal disease characterized by intestinal malabsorption of virtually all nutrients and precipitated by eating gluten-containing foods.

System(s) affected: Gastrointestinal
Genetics: See Risk factors
Incidence/Prevalence in USA: 50-75 in 100,000
Predominant age: Two incidence peaks, age 1 and 60's
Predominant sex: Female > Male (3:2)

SIGNS AND SYMPTOMS

Diarrhea
Steatorrhea
Muscle cramps
Vertigo
Nervousness
Weight loss
Failure to thrive
Weakness
Lassitude
Fatigue
Large appetite
Abdominal distention
Explosive flatulence
Abdominal pain, nausea, vomiting are rare

CAUSES

Sensitivity to gluten, specifically gliadin fraction

RISK FACTORS

First order relatives - 10% incidence
71% in monozygotic twins

DIAGNOSIS

LABORATORY

Positive anti-gliadin IgA and IgG
Positive anti-reticulum and anti-endomysial antibodies
72 hour fecal fat showing greater than 7% fat malabsorption
D-Xylose test showing malabsorption of this sugar
Decreased calcium
Decreased prothrombin time
Decreased neutral fats
Decreased cholesterol
Decreased vitamin A
Decreased vitamin B12
Decreased vitamin C
Decreased folic acid
Decreased iron
Decreased total protein
Anemia

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Small bowel biopsy - flattened villi, hyperplasia and lengthening of crypts, infiltration of plasma cells and lymphocytes in lamina propria

SPECIAL TESTS

Endoscopy

IMAGING

Upper GI series showing flocculation of barium, edema and flattening of mucosal folds

DIAGNOSTIC PROCEDURES

Biopsy of the duodenal mucosa with repeat endoscopy and normal biopsy on a gluten-free diet is necessary before a firm diagnosis can be made.

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient

GENERAL MEASURES

Removal of gluten from the diet. Rice, corn and soybean flour are safe, palatable substitutes.

SURGICAL MEASURES

N/A

ACTIVITY

No restrictions

DIET

Removal of gluten - wheat, rye, barley and those with gluten additives

PATIENT EDUCATION

Clinical dietitian
Copy of gluten-free diet
Possible lay self-help group
American Celiac Society, 45 Gifford Avenue, Jersey City, NJ 07304,
(201)432-1207.
Gluten Intolerance Group (206) 325-6980

FOLLOW UP

PREVENTION/AVOIDANCE

Avoid all gluten containing products

POSSIBLE COMPLICATIONS

Malignancy - less than 10% of patients (50% of which are small bowel lymphoma)
Refractory sprue - may respond to prednisone 40-60 mg/day po. Refractory sprue unresponsive to corticosteroid therapy raises the specter of adult-onset autoimmune enteropathy or cryptic T-cell lymphoma. In this circumstance, screening for antienterocyte autoantibodies and careful scrutiny of the small intestine, including retroperitoneal lymph node biopsy with full thickness small bowel biopsy may be needed.
Chronic ulcerative jejunoileitis - associated with multiple ulcers, intestinal bleeding, strictures, perforation, obstruction, peritonitis - 7% mortality
Osteoporosis secondary to decreased vitamin D and calcium absorption
Dehydration
Electrolyte depletion
Death (rare)

EXPECTED COURSE AND PROGNOSIS

Good with correct diagnosis and adherence to gluten free diet. Feel better in seven days. All symptoms usually disappear in four to six weeks. It is unknown whether strict dietary adherence decreases cancer risk.

MISCELLANEOUS

ASSOCIATED CONDITIONS

May have secondary lactase deficiency
Extraintestinal manifestation may include marked decrease in bone density
Dermatitis herpetiformis

AGE-RELATED FACTORS

Pediatric: Children reaching adolescence may outgrow intolerance to wheat but should be cautioned to watch for signs of recurrence in middle age
Geriatric: N/A
Others: N/A

PREGNANCY

No significant effect

OTHER NOTES

The most common cause of refractory diarrhea is noncompliance with a gluten-free diet

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

Holistic healing that treats the person, not just the disease. Experience gentle, lasting wellness with expert constitutional care.