What is celiac disease ?
Celiac disease or native thrush is a chronic intestinal disease, is characterized by an innate gluten intolerance that leads to an inadequate diet to damage of the intestinal mucosa. The condition is most likely caused by an immune response against one of the proteins of the gluten complex. Antibodies in such a reaction are being formed from the IgA class. Gluten is the name for a group of proteins found in all grains, but not all grains contain the gliadin fraction, which is the causes of celiac disease. Rice and corn are cereals containing gluten indeed, but no gliadin. The condition results in these patients to a reduced absorption of nutrients which improves when following a gluten free diet. Celiac disease for many decades, primarily associated with gastrointestinal symptoms. More recent research shows that for every patient with gastrointestinal symptoms, there are eight without these symptoms.
Pathogenesis
Meanwhile, some of the harmful components of the adhesive protein identified. They belong to the alcohol-soluble fraction of wheat proteins (including barley, spelled and rye contain protein components, called prolamin). These components are called gliadin, and contain many of the amino acids proline and glutamine. These components generate a hypersensitivity reaction of the immune system and intestinal mucosa in patients who are predisposed. The immune system of these people recognize the gluten as "dangerous" which follows an immune and inflammatory response. The mucus layer cells (enterocytes) produce several HLA class. Certain components of the adhesive protein (the gliadinepeptide) bind to the abundant in these patients HLA-DQ2-antigens. This bond is reinforced by which glutamine is present in large numbers in the gliadinepeptide. The enzyme tissue transglutaminase-producing glutamic acid from this glutamine.
Various antibodies are formed in a more advanced phase of the inflammation. Of these antibodies, one does not know up to now, or they are a causative factor in the occurrence of celiac disease or that they are formed by associated auto-immune reaction. In addition to antibodies to the protein self-adhesive (gliadin antibody) are also antibodies against self-antigens for (so-called auto-antibodies), such as against the tissue transglutaminase. On the basis of this observation is from celiac disease pathophysiological basis also considered to be autoimmune disease. Gliadin is the triggering component of the disorder. For the realization of the symptoms is essentially the auto-immune response to self proteins responsible. As a final phase of the inflammatory cascade occurs in programmed cell death of the enterocytes. This cell death leads to a more or less pronounced loss of intestinal villi (villous atrophy). This nutrients are not properly absorbed (which among other things leads to energy loss and slimming, and for children to poor growth) and often a greasy, voluminous diarrhea.
Marsh Classification
The classic pathological changes in celiac disease can be categorized according to the "Marsh Classification":
- Marsh stage 0: normal mucosa
- Marsh stage 1: increased number of intraepithelial lymphocytes, usually exceeding 20 per 100 enterocytes
- Marsh stage 2: proliferation of the crypts of Lieberkühn
- Marsh stage 3: partial or complete villusatrofie
- Marsh Phase 4: hypoplasia of small intestine architecture
In some cases, a test can be done after eating gluten to accept the diagnosis or to refute (gluten challenge). A typical biopsy and serology after this test can be an indication that the initial diagnosis was incorrect. Patients should be warned that one should not outgrow the disease (as with some food intolerances in children), and we therefore must follow a lifelong gluten-free diet.
Celiac disease symptoms
The symptoms of celiac disease were first described by the Greek physician Aretaeos in the year 100. The typical gastrointestinal symptoms gave the disease its name: 'Koilia' is Greek for womb. The symptoms vary greatly between patients. In children between 9 and 24 months are stunted and bowel-related symptoms (following on from the first contact with gluten-containing products) first. Older children can mainly absorption-related symptoms and psychosocial problems are present. In adults are symptoms that are related to the malabsorption of nutrients first. The classic symptoms are diarrhea, bloating, weight loss and fatigue. Despite the chronicity of the disease, the symptoms are often mild allowing many patients seek help around 50 years of age. They present themselves with mild manifestations of the disease such as fatigue or anemia. In some cases there is a typical vesicle-forming skin (dermatitis herpetiformis) adjacent to the bowel disorder.
Next symptomatology is seen in celiac disease:
- chronic diarrhea
- irregular bowel movements, excessive discharge and / or constipation (constipation)
- weight Loss
- stunted growth (especially in young children)
- abdominal distension
- anemia
- lack of appetite
- vomit
- listlessness
- drowsiness
- bone loss (osteoporosis)
- strong mood swings
- a late puberty
- muscle problems
- fertility problems
- nerve disorders
- psychological symptoms
The characteristic diarrhea in celiac disease is pale and bulky with a pungent odor. Abdominal pain and cramping, abdominal distension (by fermentation in the colon) and ulcers in the mouth may be present. With the progression of the disease can develop itself to a certain extent, a lactose-intolerance. However, the range of gastro-intestinal symptoms is very wide. The complaints are therefore often attributed to irritable bowel syndrome to be recognized later as celiac disease. A small proportion of patients with IBS have underlying celiac disease screening in which this condition therefore seems appropriate.
Celiac disease is associated with an increased risk of developing adenocarcinoma and malignant lymphoma of the small intestine. The risk of these malignancies will return to base level in the monitoring of an adjusted gluten-free diet. The persistence of this condition can also lead to the formation of ulcers jejunum and the narrowing of the intestinal lumen by scarring.
Symptoms related to malabsorption
The changes in the mucous membrane of the small intestine makes it harder to nutrients, minerals and fat-soluble vitamins (A, D, E, K) to absorb:
- The difficulties to absorb carbohydrates and fats may cause weight loss and fatigue (or growth disorders / stunted growth in children);
- Anemia can develop through various ways such as the malabsorption of iron (iron deficiency anemia), folic acid and vitamin B12 (megaloblastic, pernicious anemia);
- The malabsorption of calcium and vitamin D (and compensatory secondary hyperparathyroidism) may cause osteopenia (decreased mineral content of the bone) or osteoporosis (reduction in bone density with normal mineral levels);
- A small proportion of patients (10%) have an abnormal blood clotting caused by a deficiency of vitamin K.
- Celiac disease is also associated with bacterial colonization of the small intestine (small intestinal bacterial overgrowth, SIBO).
Celiac disease diagnosis
The diagnosis is usually made by a pediatrician or an internist. Similarly, certain antibodies in the blood can be detected (anti-gliadin and anti-endomysium antibodies) that are likely to make the diagnosis. On the basis of the symptoms is the diagnosis in typical cases it is often already quite certain, but necessary for a definitive diagnosis is an endoscopy of the small intestine, wherein a biopsy of the intestinal tissue is made, which shows the typical inflammatory response of the intestinal wall. The tests, however, lose their usefulness when the patient is already established on a gluten-free diet. The intestinal lesions start to heal within a few weeks after the patient has started a gluten-free diet.
Endoscopy is indicated when some core symptoms are present or there exists a positive serology. In a study to be following core symptoms considered indicative of an endoscopy:
- severe weight loss or gain (with a bulb / abdominal distension)
- anemia (hemoglobin less than 120g / l in women and less than 130 g / l in men)
- diarrhea (more than three times a day).
Celiac disease treatment
The treatment consists of the follow a strict gluten-free diet. Usually, the intestinal epithelium recovers, so that intestinal function and restores all symptoms disappear. The celiac sufferers bound their lives to following the strict diet. In some patients eating one morsel "just" bread lead to the (temporary) return of the symptoms. More and more doctors believe that a celiac patient does not adhere well to the diet has a greater risk of colon cancer.