Celiac Disease: Missed Diagnosis
Celiac disease is an autoimmune disorder that often escapes diagnosis. As many as 50 to 60% of patients have no symptoms. Patients with this condition are allergic to grains (wheat, oats, rye, barley, triticale, spelt). When the gluten from wheat or other grains is eaten, antibodies are made that over a period of years injure the projections on the surface of the small intestine (villi). The surface of the small bowel becomes flat and normal absorption fails. Diseases that are often confused with Celiac Disease include irritable bowel syndrome, iron deficiency anemia from menstrual bleeding, Crohn’s Disease, diverticulitis, intestinal infections and chronic fatigue syndrome.
Celiac disease is common in countries that eat wheat and rare in China and Japan where rice is consumed. A recent JAMA paper reported that the incidence of CD in children ranges between one in 57 to one in 33, so this appears to be a common condition when carefully looked for. Early diagnosis and dietary therapy may prevent the development of other related autoimmune illnesses. A very specific test for the disease is the test for antibodies to an individuals own enzyme antiTG (anti-tissue transglutaminase). This test will be negative if the patient has not eaten gluten (wheat) for a long time, so it is advisable to postpone this test until the patient has been back eating wheat for a week or two.
Symptoms of gastrointestinal disease are nonspecific and symptoms in other organs are fifteen times more frequent non viral hepatitis, osteoporosis, unsteady gait (ataxia), Type 1 diabetes, hair loss, psoriasis, polyneuritis, vasculitis, thyroiditis, Sjogren’s syndrome, rheumatoid arthritis, adrenal insufficiency, infertility, anemia, depression, and lymphoma and cancer of the small intestine. The best test to establish the diagnosis is small bowel capsule biopsy, which is safe and only infrequently fails to prove the diagnosis. Failure to find this disease with continued wheat intake in children can be followed by poor growth and impaired brain development. The death rate in CD patients is twice that of normal individuals. Of 128 men and women with osteoporosis, 12 (9.4%) were found to have celiac disease. Patients with celiac disease usually have a many-year history of faulty absorption of minerals, which could explain the osteoporosis.
In a review of 185 adults who had liver transplantation, eight persons (4.3%) were discovered to have celiac disease. Four more patients being considered for liver transplantation were found to have celiac disease. All four had improved liver function following implementation of a gluten free diet. All patients with severe unexplained liver disease need to be screened for celiac disease. Many children with autism have small intestine damage, but only a few test positive for CD antibodies. A strict gluten-free, casein-free diet in these children led to improvement that disappeared when the diet was stopped. The problem in these children is believed to be food allergies(wheat, dairy) causing incomplete digestion of proteins, so that peptides are able to enter the blood stream and produce pain and diarrhea.
Dr. Jonathan Wright and investigators in Australia have learned that many patients (30%) with systemic lupus erythematosus have hidden allergies to gluten. When placed on a gluten free diet, these patients lose their symptoms of lupus and their blood tests for lupus revert to normal. The family history of these patients is loaded with autoimmune illness(lupus, rheumatoid arthritis, psoriasis, M.S., myasthenia gravis, asthma). Dermatitis Herpetiformis is characterized by a skin rash with severe itching and blisters often found on the elbows, knees and buttocks. Twenty percent of patients with DH have Celiac Disease. Some psoriasis patients have antibodies to IGA endomysium and these respond with marked improvement on a gluten free diet.
A different investigation disclosed that incidence of CD is only one in every 133 persons. This helps prove that hundreds of thousands of persons with CD are escaping diagnosis. When studied between 5 and 15% of relatives of CD patients are also found to have CD. Three to eight percent of Type 1 diabetics have CD. The dietary therapy of CD is quite complex because minute quantities of gluten in the diet impede healing. Many conglomerate produced packaged foods contain gluten without any wheat labeling. Wheat products are often used as thickeners, stabilizers and texture enhancers in mass produced foods. An intelligent informed dietitian is imperative in counseling. A good gluten free diet leads to complete healing in 3 to 6 months. Foods that can safely be eaten by CD patients include potatoes, rice, amaranth, quinoa, buckwheat and bean flour.