What is coeliac disease?

known as gluten enteropathy or coeliac sprue. lifelong condition of the small intestine (bowel). Gluten is a mixture of two proteins, gliadin and glutenin. It is found in wheat, barley and rye. When combined with water gluten becomes sticky and forms the familiar texture of dough. In coeliac disease, gluten causes the immune system to produce antibodies that attack the delicate lining of the bowel, which is responsible for absorbing nutrients and vitamins from food. can be diagnosed at any age, but often diagnosed in babies after weaning, when cereals are first introduced into the diet. The symptoms can be subtle, and you may feel unwell for some time for no reason before the diagnosis is made. If left untreated, coeliac disease can lead to anaemia, bone disease and, rarely, some forms of cancer. Avoiding all food that contains gluten usually results in the improvement, or even disappearance, of damage to the bowel lining. However, the damage will start again if gluten is re-introduced into the diet.

How does gluten damage the bowel?

Damaged villi Healthy villi of the small intestine (as seen under the microscope).

Villi completely

destroyed by immune s. The small bowel contains villi which provide a large surface area over which we absorb nutrients such as vitamins, folic acid, iron and calcium. If you have coeliac disease, a reaction occurs when gluten comes into contact with the lining of the small bowel. The villi are attacked by the immune system and are eventually destroyed villous atrophy. This results in nutrients from food going down the gut without being absorbed (malabsorption), leading to diarrhoea, vitamin and mineral deficiencies, anaemia and thin bones (osteoporosis).

Who is at risk?
It used to be thought that coeliac disease affected about 1 in 1500 people. More accurate diagnosis through blood tests has shown that the condition affects up to 1 in 300 people in the United Kingdom, Europe and the USA. It is more common in some areas of the world, particularly on the west coast of Ireland, where 1 in every 100 people are thought to have coeliac disease. Coeliac disease can affect you at any age. It was thought to be more common in men, but probably occurs equally in men and women. Coeliac disease is sometimes associated with other conditions. People with Type 1 diabetes, thyroid problems and ulcerative colitis have an increased chance of developing coeliac disease. Genetic risk factors If you have a parent, sibling or child with coeliac disease, you have a 10 per cent chance of also developing it. If you have an identical twin with coeliac disease, your chances increase to more than 70 per cent.

Symptoms?
In childhood symptoms do not appear until gluten-containing foods (bread, cereal) are introduced into the diet.

Poor appetite, irritability and a failure to gain weight are usually the first symptoms. Pale, bulky stools that smell nasty. Vomiting and diarrhoea, which can lead to a wrong diagnosis of gastroenteritis. Swollen stomach. Arm and leg muscles may become wasted and thin.

Adult symptoms
In adults symptoms include:

weight loss with pale, offensive diarrhoea constipation abdominal bloating with wind.

Half of adults with coeliac disease do not have any of these bowel symptoms. They approach their doctor because of:

extreme tiredness which is a sign of anaemia psychological problems like depression bone pain/fractures which are due to thinning of the bones ulcers in the mouth a blistering, itchy skin rash mostly on the elbows/knees -dermatitis herpetiformis.

In one neurology clinic, several patients who, for no apparent reason, had difficulty walking and coordinating (ataxia) were tested for coeliac antibodies in the blood. A significant number were found to have coeliac disease, although many of them did not have any gut symptoms.

How is coeliac disease diagnosed?

Your doctor may also want to know whether you have lost weight or whether you have symptoms of anaemia (tiredness, exhaustion, pallor). The doctor may:

examine your abdomen look for a blistering rash on your skin check for mouth ulcers.

Blood tests are then usually requested.

Check for anaemia, test levels of iron, folic acid and calcium in blood. Another blood test detects antibodies that are often found in coeliac disease. Several antibodies are linked to the condition, but the most specific is antiendomysial antibody. If this is present in the blood, you are very likely to have coeliac disease.

An endoscopy test is needed to diagnose coeliac disease. Your doctor should arrange this test at the endoscopy unit at your local hospital. You can usually choose to have the test under general anaesthetic (sedation) or have a local anaesthetic that numbs the throat with a spray.

Endoscopy and biopsy

A thin flexible tube with a tiny camera and clipper at its end is put into your mouth. The camera is guided down the oesophagus (gullet) into the stomach and then the small bowel. The clipper can be used to remove a small piece of the bowel lining during the procedure. This is called a biopsy. You will not feel any discomfort. The whole procedure takes about 10 minutes. The biopsy specimen will be sent to the laboratory to examine the size and shape of the villi. This will confirm diagnosis. It is usual to repeat this test after several months on a gluten-free diet, to check that the lining has recovered.

What else could it be?

Diarrhoea and weight loss can be due to several other causes.

A bowel infection caused by parasites called Giardia lamblia and Strongyloides. If your symptoms start after a tropical holiday, one of these infections may be to blame. Overgrowth of bacteria in the small intestine. Lactose (milk) intolerance. Whipple's disease (a rare disease in men that prevents nutrients and fat being absorbed). Intestinal lymphoma (a type of cancer).

What treatment is available?

It's not possible to prevent coeliac disease, but a gluten-free diet can reverse damage to the small intestine. This requires considerable discipline. After diagnosis your GP should refer you for a consultation with a dietitian, who can give you diet sheets and advice. Another important aspect of treatment is replacing vitamins and minerals. You may need iron tablets, folic acid supplements (especially when pregnant or planning to get pregnant) and calcium. Severe coeliac disease that does not get better on a gluten-free diet may need tablets that 'damp down' the immune system, such as steroid tablets. This is rare. Avoiding gluten does not cause serious side-effects. However, gluten-free food does tend to be low in fibre and can cause constipation in some people. To counteract this, eat plenty of fruit and vegetables. If constipation persists, try rice bran or a laxative called Fybogel, which is available with or without a prescription from your pharmacy.

What is a gluten-free diet?

Things to avoid
Gluten is found in the following foods.

Bread, pasta and breakfast cereals. Biscuits, cakes and pastries. Malt vinegar, soy sauce, mustard and mayonnaise. Some tinned soups and sauces. Gluten is also hidden in some foods such as crisps and similar snacks, as well as chips in restaurants. Cooking oil (mixed vegetable oil) can contain wheat-germ oil, so use sunflower or olive oil instead. Beer and whisky are made from grain containing gluten, but other alcoholic drinks such as wine and cider are gluten-free.

Oats have generally been shown not to upset people with coeliac disease, but are probably best avoided. This is because oats may contain a small amount of gluten, and are often processed and stored in the same mills as wheat. This means they can be contaminated with gluten. Some medicines contain gluten, so you must check with your doctor or pharmacist before taking them.

Foods you can eat

Many foods do not contain gluten, including:

all fruit, salads, vegetables potatoes rice and maize nuts red meat, chicken, fish, eggs and dairy products.

Gluten-free substitutes are available from most supermarkets and pharmacies. You can also get staples such as gluten-free flour, breads, biscuits and pasta on prescription from your doctor. There are excellent books available on gluten-intolerance, including general guides and recipe books.

What complications can coeliac disease cause?

Complications of coeliac disease are rare. They include the following. Term watch

Autoimmune disease: a disease where the immune system attacks the body's own cells. Coeliac disease is an autoimmune disease.

Infertility in women. Recurrent miscarriage is sometimes associated with coeliac disease. Severe anaemia in pregnancy because the bowel cannot absorb enough iron and vitamins to keep up with the demands of mother and baby. Intrauterine growth retardation. Babies who are small for their age in the womb are more frequently born to mothers with coeliac disease. Autoimmune diseases (thyroid disease, Type 1 diabetes and some types of liver disease such as primary biliary cirrhosis). Thinning of the bones (osteoporosis). A slightly increased risk of developing bowel cancer, intestinal lymphoma and cancer of the oesophagus.

A gluten-free diet reduces all these complications, as well as associated conditions such as dermatitis herpetiformis and mouth ulcers. Studies have shown that sticking to a gluten-free diet for five years or more reduces the risk of all cancers associated with coeliac disease to that of the general population.

Is there a cure for coeliac disease?

A gluten-free diet should enable the lining of the bowel to return to normal in most people. But damage will return as soon as you start eating gluten again. This means the disease can be 'cured', but only by avoiding foods that contain gluten. If you do this, you can enjoy a good quality of life without symptoms or long-term complications. Anaemia low iron less Hb Megaloblastic Anemias B12/folate deficiency high mcv (Classical vitamin B,, or folate deficiency causes an increase in erythrocyte size because the RBC is unable to make haemoglobin this accumulates making the cell bigger Vit B12 FolateFH4 form DNA Pernicious anaemia - B12/Intrinic factor complex needed for ab of B12. Autoimmue IgG attack gastric parietal cells and Intrinsic Factor