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Coeliac disease

 


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Condition
Coeliac disease
Class
Gastrointestinal system
Description
Coeliac disease (also known as gluten-sensitive enteropathy or coeliac sprue) is an inflammatory disorder of the gastrointestinal tract caused by sensitivity to gluten proteins that are found in wheat, barley and rye.

Coeliac disease is very common, affecting about 1 in 100 people in the UK. In families that already have coeliac disease, it affects about 1 in 10 people, suggesting a genetic link. Coeliac disease is also more common in people with type 1 diabetes and thyroid diseases. It is more common in females than males, but it can affect people of all ages, children and adults, although in some symptoms are not always obvious and the condition may remain undiagnosed.
Causes
Susceptibility to coeliac disease involves a combination of genetic, environmental and immune factors. The gluten proteins found in wheat, rye and barley are rich in the amino acids proline and glutamine. The high proline content renders these gluten proteins resistant to complete breakdown by the digestive enzymes with the result that large peptides (partially digested proteins) with a high proline and glutamine content accumulate in the small intestine. Normally, these large peptides are not able to pass through the intestinal wall. In patients with coeliac disease it is thought that intestinal inflammation increases the permeability of the intestinal wall, allowing these peptides to pass through. Once through the intestinal wall, the peptides are broken down by an enzyme called tissue transglutaminase, but this triggers an immune response that produces antibodies against transglutaminase. As this enzyme is responsible for maintaining the villous layer (the delicate finger-like projections of the small intestine where absorption of food takes place), normal digestion and absorption of nutrients, vitamins and minerals is prevented, leading to malnutrition and causing diarrhoea.

Tissue transglutaminase also maintains the integrity of the skin, so the development of antibodies to the enzyme is also thought to be responsible for the skin lesions called dermatitis herpetiformis found in some people with coeliac disease.
Symptoms
The symptoms of coeliac disease arise as a result of the failure to absorb nutrients. Insufficient amounts of vitamins and minerals are absorbed to maintain healthy growth and sustain the body. There is a failure to gain weight, muscles waste away, anaemia develops so the person becomes tired and breathless. If insufficient calcium is absorbed, osteoporosis may eventually develop. The presence of minerals and non-absorbed food in the intestine causes the person to pass very pale, sticky and smelly bowel motions and they will often have bouts of diarrhoea. The abdomen may swell and become painful.

Some people develop a distinctive rash called dermatitis herpetiformis. In rare cases, coeliac disease causes infertility and some people may develop cancer of the small intestine.

Symptoms of coeliac disease are not always obvious and in some people with mild symptoms the condition may remain undiagnosed for years, only being discovered when other members of the family have been found to have coeliac disease.

In babies, symptoms of coeliac disease may first appear when cereals are introduced to the baby's diet. In children, symptoms may become obvious when the child does not appear to grow as fast as his or her class mates. While in adults, symptoms may develop gradually.

Severe stress or an infection may lead to the appearance of symptoms.
Diagnosis
Diagnosis is a simple procedure, which involves two steps:

Step 1: a simple blood test carried out by a doctor. There are two blood tests that can be done:
  • Endomysial antibodies (EMA)
  • Tissue transglutaminase antibodies (tTGA)

It is possible to have a negative blood test but still have coeliac disease.

Step 2: a biopsy is taken in a hospital by a gastroenterologist. This involves an endoscope being passed via the mouth and into the small intestine, to obtain small tissue samples which are examined under a microscope to check for the typical abnormalities of the small intestine that occur in coeliac disease.

Important points to remember if having the biopsy:
  • Do not remove gluten from the diet - continue to eat a normal diet including bread, pasta and cereals until after the blood test and biopsy.
  • If gluten has already been eliminated from diet it must be re-introduced for at least six weeks before the tests are performed.
Treatment
Although corticosteroids may be used to control severe inflammatory reactions, there are no medicines to treat coeliac disease. The only method is a total and lifelong avoidance of wheat, barley and rye. To prevent symptoms of coeliac disease from occurring it is essential to eliminate gluten completely from the diet. Even very small amounts of gluten must be avoided and people must follow a strict gluten-free diet.

Improvement in symptoms begins within days of starting a strict gluten-free diet. The small intestine begins to recover and is usually completely healed in 3 to 6 months. Normal development in children resumes and people begin to regain lost weight and their energy levels recover.
When to consult your pharmacist
It is easy to become bored following a strict gluten-free diet. Talk to your pharmacist about the range of gluten-free products that are available. In addition to gluten-free bread, there are biscuits in a variety of flavours, crackers, crispbreads, all forms of pasta, cake and pastry mixes.

Your pharmacist will also be able to advise you about eating a healthy balanced diet that will help avoid constipation, a common occurrence in those following a gluten-free diet that may lack fibre.
When to consult your doctor
You should talk to your doctor if you suspect you or a relative has coeliac disease which has not been diagnosed or if there is a history of food intolerance or coeliac disease in your family. Your doctor will talk to you about your symptoms and may decide to perform a blood test or send you for a biopsy to confirm the diagnosis.

If diagnosed with coeliac disease, your doctor will advise you to follow a strict gluten-free diet. You may also be advised to see a dietician who will tell you about which foods to avoid. The dietician will also provide you with recipes for gluten-free meals. There is a wide variety of gluten-free products available on prescription that will help you stick to your gluten-free diet.

Your doctor may also prescribe iron, vitamin B or folic acid supplements to correct anaemia, or calcium and vitamin D supplements to prevent osteoporosis from developing if these minerals and vitamins are lacking in your diet.

It is important that you have regular check-ups with your doctor to make sure that your condition is still being controlled. You should also talk to your doctor if symptoms persist after changing your diet or if you experience abdominal pain.
Living with coeliac disease
As even small quantities of gluten may trigger immune reactions it is important that you avoid gluten entirely.

Learn to recognise foods that contain gluten and get into the habit of reading labels on food items because many products use wheat, rye or barley flour as an ingredient. Look too for food products that carry the crossed grain symbol which indicates that the product is suitable for people with coeliac disease. Take particular care when eating in restaurants; always ask if you have any doubts about whether gluten has been used in the preparation of sauces etcetera.

Here are some examples:

Foods that contain gluten and which should be avoided: wheat, barley, rye and foods made from flour from these cereals such as bread, rolls, pasta, crisp breads, buns, biscuits, cakes, pastries, beer, pizza, sausages, breakfast cereals, gravies, sauces, breadcrumbs, batter.

Foods that are gluten-free and which may be eaten: Rice and maize are naturally gluten-free cereals that can be used as a basis for meals on the gluten free-diet. Fruit, vegetables and pulses are totally gluten-free. Other foods that are gluten-free include meat, fish, eggs, cheese and soya. Once foods are processed the risk of cereal being added increases eg breaded ham. Dairy foods like milk, cheese, eggs, yogurt and cottage cheese are all gluten-free but once ingredients are added they need to be checked. Thickening agents for sauces that are gluten-free include arrowroot and corn flour.

You may find it difficult to stick to a gluten-free diet at first, but talk to your dietician for help and for suggestions about menus.

If you do eat gluten by mistake you will usually start to experience symptoms within a few hours. The effects can last from a few hours to several days depending on the amount of gluten you have eaten and your body's response to the gluten. If you experience diarrhoea or vomiting it is important, especially for children or frail individuals, to replace the fluids that have been lost by taking an electrolyte supplement or by drinking plenty of water. Additionally, an antidiarrhoeal medicine such as loperamide may help.

As your experience grows and you begin to recognise the products that you can and cannot eat, these types of mistakes will become far less common.
Advice to and for other family members and friends
If a member of your family has coeliac disease it is essential to take sensible steps to prevent contamination with gluten-containing foods in the kitchen. For example, use a separate toaster for toasting gluten-free bread.

Cooking for the family does not have to be a chore. Many everyday dishes can be made gluten-free by substituting some ingredients or using special gluten-free products.

If your child has coeliac disease it is important to explain what coeliac disease is and what gluten does to the body as early as possible. You will not be able to keep an eye on what your child is eating all of the time and it is only by your child understanding coeliac disease will she or he learn what foods to avoid.

Get your child involved in identifying foods that are gluten-free to help understand her/his diet. Go through your cupboards, mark products that are gluten-free which can be eaten and use a different mark for products that are not gluten-free and which cannot be eaten. Marking products in this way will also help other family members and friends.

Tell other members of the family and your child's friends about your child's condition, so that they too know that gluten should be avoided.
Useful Tips
  • Eat a balanced diet with plenty of fruit and vegetables
  • Make sure that your diet is rich in calcium
  • Get plenty of exercise
  • Refer to your local dietician for specific dietary advice
  • Drink plenty of water - 6 to 8 glasses a day
Further information
Coeliac UK is the leading charity working for people with coeliac disease and dermatitis herpetiformis. Its mission is to improve the lives of people with coeliac disease through support, campaigning and research. Coeliac UK provides expert and independent information to help people manage their health and diet.

Coeliac UK
3rd Floor
Apollo Centre
Desborough Road
High Wycombe
Bucks
HP11 2QW
Tel: 01494 437278
Helpline: 0845 305 2060 Website: www.coeliac.org.uk

Reviewed on 10 November 2010


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