Celiac disease - sprue

Definition

Celiac disease is an inherited, autoimmune disease. The lining of the small intestine is damaged from eating gluten and other proteins found in wheat, barley, rye, and possibly oats.

The intestines contain projections (called villi) that absorb nutrients. In undiagnosed or untreated celiac disease, these villi become flattened, and the ability to absorb nutrients properly is altered. As a result, several other organ systems may also be affected. The disease can develop at any point in life, from infancy to late adulthood.

Alternative Names

Causes

The exact cause of celiac disease is unknown. Once thought rare, celiac disease has recently been estimated to affect 1 of every 133 Americans. However, only a small fraction of people living with celiac disease in the United States have been diagnosed at this time.

Those with a family member with celiac disease are at greater risk for developing the disease. The disorder is most common in Caucasians and those of European ancestry. Women are affected more commonly than men.

There are numerous diseases and conditions associated with celiac disease, including:

• Anemia
• Lactose intolerance
• Dermatitis herpetiformis (a burning, itching, blistering rash), and other skin disorders
• Type 1 diabetes
• Thyroid disease
• Down syndrome
• Unexplained infertility
• Miscarriage
• Osteoporosis or osteopenia
• Certain types of intestinal cancer
• Neurological conditions
• Autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus

Symptoms

The symptoms of celiac disease can vary significantly from person to person. Symptoms may be intestinal or seemingly non-intestinal in nature. This variability is part of the reason the diagnosis is frequently delayed. For example, one person may have constipation, a second may have diarrhea, and a third may have no irregularity in stools.

A partial listing of gastrointestinal symptoms:

• Abdominal pain
• Abdominal distention, bloating, gas, indigestion
• Constipation
• Decreased appetite (may also be increased or unchanged)
• Diarrhea, chronic or occasional
• Lactose intolerance (common upon diagnosis, usually goes away following treatment)
• Nausea and vomiting
• Stools that float, are foul smelling, bloody, or "fatty"
• Unexplained weight loss  (although people can be overweight or of normal weight upon diagnosis)

A partial listing of non-intestinal symptoms:

• Anemia (low blood count)
• Bone and joint pain
• Bone disease (osteoporosis, kyphoscoliosis, fracture)
• Breathlessness (due to anemia)
• Bruising easily
• Dental enamel defects and discoloration
• Depression
• Fatigue
• Growth delay in children
• Hair loss
• Hypoglycemia (low blood sugar)
• Irritability and behavioral changes
• Malnutrition
• Mouth ulcers
• Muscle cramps
• Nosebleed
• Seizures
• Short stature, unexplained
• Skin disorders (dermatitis herpetiformis)
• Swelling, general or abdominal
• Vitamin or mineral deficiency, single or multiple nutrient (for example, iron, folate, vitamin K)

Exams and Tests

A complete blood count (CBC) may indicate anemia. It is important to determine the cause if anemia is detected. An elevated alkaline phosphatase level may indicate bone loss, which is commonly experienced before diagnosis. Low cholesterol and albumin levels may reflect malabsorption and malnutrition. Mildly elevated liver enzymes and abnormal blood clotting may also be noted.

There are several antibody blood tests that are useful in screening. A panel consisting of antiendomysial antibody (IgA), antitransglutaminase (IgA), antigliadin (IgA and IgG), and total serum IgA is typically ordered. Combined, these antibodies provide a sensitive and specific indicator for the presence of celiac disease.

An endoscopy (EGD) with small bowel biopsy, particularly of the lower sections of the intestine most commonly affected, will show an abnormal intestinal lining (flattening of the villi).

A follow-up biopsy or blood work may be ordered several months after the diagnosis and treatment. These serve as a final confirmation of the disease. Normal results mean the patient has responded to treatment, thereby confirming the diagnosis. However, this does not suggest that the disease has been cured. Ongoing treatment for celiac disease is the gluten-free diet.

Treatment

You must follow a life-long gluten-free diet. This allows the intestinal villi to heal. Foods, beverages, and medications that contain wheat, barley, rye, and possibly oats should be eliminated completely. You must read food and medication labels carefully to look for hidden sources of these grains and their derivatives. Since wheat and barley grains are found abundantly in the American diet, keeping to this diet is challenging. With education and planning, you will achieve the goal of healing.

You should NOT begin the gluten-free diet before a diagnosis is made. Doing so will alter future testing for the disease.

Vitamin and mineral supplements may be prescribed to correct nutritional deficiencies. Occasionally, corticosteroids (such as prednisone) may also be prescribed for short-term use or if you have refractory sprue. Following a well-balanced, gluten-free diet is generally the only treatment required for staying well.

Upon diagnosis, seek consultation from a registered dietitian with a specialty in celiac disease and the gluten-free diet. A support group may also help you cope with the disease and diet.

Support Groups

For additional information and support, see the organizations listed in celiac disease resources.

Outlook (Prognosis)

Removing all damaging grains from the diet is the most important measure you can take to become healthy. If you follow the diet strictly, you can expect to lead a long, healthy life -- if permanent damage did not occur before diagnosis.

Possible Complications

The gluten-free diet must be carefully and continuously followed. When untreated, the disease can cause life-threatening complications. A delayed diagnosis or non-compliance with the diet places you at risk for developing associated conditions such as infertility, miscarriage

When to Contact a Medical Professional

Call your health care provider if symptoms develop that are suggestive of celiac disease.

Prevention

Because the exact cause is unknown, there is no known way to prevent the development of celiac disease. However, being aware of the risk factors (such as having a family member with the disorder) may increase your chances of early diagnosis, treatment, and a long, healthy life.