Celiac disease affects the gastrointestinal tract - especially the small intestines. It is seen in genetically predisposed children and adults.
The symptoms are usually precipitated by the ingestion of gluten-containing foods. Alternative names for celiac disease are celiac sprue, gluten-sensitive enteropathy, and nontropical sprue.
What is Gluten?
Gluten is a form of plant based protein. It is present in wheat, rye, and barley and gives the dough for bread its baking properties.
Cakes, bread, pasta, breakfast cereals, sauces, beer (made from barley) and ready meals may contain gluten.
Pathology of celiac disease
Celiac disease is an autoimmune condition. The gluten protein makes the immune system sensitive. The overactive immunity thus attacks and damages the surface of the small intestines disrupting the body’s ability to absorb nutrients from food.
Who is affected be celiac disease?
Caucasians are not the only race that is affected. Other races and ethnicities are equally affected.
The risk is higher if a first-degree or a second-degree relative is affected. First degree relatives like parents, offspring and siblings are at greatest risk. This suggests a genetic association. Patients with celiac disease may often suffer from infertility.
Symptoms of celiac disease
In most cases the diagnosis is made around 10 years after the onset of symptoms. Frequently there may be no symptoms at all.
General symptoms of the condition in response to dietary gluten include:-
- Unpleasant smelling diarrhea
- Abdominal bloating and flatulence
- Abdominal pain
- Weight loss
- Growth retardation
Prevalence of celiac disease
The prevalence of celiac disease in a healthy adult population is seen in a wide range that varies between one in 100 and one in 300 worldwide.
In the majority of these patients the symptoms may be absent or few. The female to male ratio in prevalence is 2:1.
Due to a large population without symptoms of the disease, the actual prevalence of the disease is difficult to determine. The risks are higher in first-degree relatives (up to 10%) and less so in second-degree relatives.
Those with some other autoimmune diseases, diabetes, arthritis, Down’s syndrome etc. are more at risk of the condition.
Prevalence in the United States
On average at least 1 in 133 healthy persons in the USA suffers from gluten sensitivity and celiac disease. This means nearly 3 million Americans suffer from this disease. Despite diagnosis only around 1 in 56 persons suffer from symptoms of celiac disease.
Absence of any symptoms of the condition despite diagnosis is seen in 60% of children and 41% of adults diagnosed with celiac disease. In addition, only 35% of newly diagnosed patients present with symptoms of chronic diarrhea. This goes against the traditional belief that diarrhea must be present to diagnose celiac disease.
The average length of time it takes for a symptomatic person to be diagnosed with celiac disease in the US is four years and may take up to 10 years as well. The longer this duration the greater is the risk of the patient developing complications like osteoporosis, other autoimmune diseases and cancers.
Age at diagnosis is thus related to chances of developing autoimmune conditions:-
- Diagnosed at 4 – 12 yrs of age - 16.7% chance
- Diagnosed at 12 – 20 yrs of age - 27% chance
- Diagnosed at over 20 yrs of age - 34% chance
The risk of getting celiac disease is higher among first degree relatives of sufferers by about 10%. First degree relatives include parents, children or siblings. The prevalence among first degree relatives is around 1 in 22 persons. The risk is also high among second degree relatives like uncles, aunts and cousins and the prevalence is 1 in 39.
Prevalence varies according to races and ethnicities. It was previously believed that only Caucasians were affected – this is not true. The estimated prevalence for African-, Hispanic- and Asian-Americans is 1 in 236.
Prevalence in the United Kingdom
In the United Kingdom, the prevalence of celiac disease in children by biopsy is 0.5 to 1.6% and confirmed by serology to be 0.3 to 1.9%. The numbers among adults is similar with 0.07 to1.9% confirmed by biopsy and 0.2 to 2.7% confirmed by serology.
Serological tests also reveal that IgA EMA positive rates were higher in girls than in boys, odds ratio (OR) 2.12 (95% confidence interval [CI] 1.20 to 3.75).
Studies have found a prevalence of 2.8 to 17.2% with serology and 5.6 to 44.1% with biopsy among first degree relatives of sufferers of celiac disease.
Diagnosis of celiac disease
For diagnosis the features that should be positive include:-
- Improvement in symptoms when diet is free from gluten
- Characteristic histopathology changes in an intestinal biopsy specimen
Serological tests are used to confirm the disease as well as for screening for individuals who are at risk. Serological tests are useful to detect which patients need an intestinal biopsy.
Management of celiac disease
There are no specific medications to be used for treatment of celiac disease except for avoiding dietary gluten completely. This means avoiding wheat, rye, or barley.
This diet needs to be followed for the rest of their lives. Oats are allowed in 95% of patients. Corn and rice-based diets are also allowed.
There is a higher risk of death due to complications of celiac disease and its flare ups. This excess death rate returns to normal after 3–5 years of persistent gluten-free diet.