Celiac Disease

Celiac Disease (Celiac Sprue)

What is celiac disease?

Celiac disease or celiac sprue is a disorder of the small intestine. Its cause is unknown but is related to an immune response (allergy) to certain food products. These substances which are contained in grain (gliadin, glutens) abnormally stimulate the immune system within the small bowel resulting in migration of inflammatory cells in and amongst the intestinal cells, damaging them. Since the immune system is responsible for the abnormality within the small intestine, celiac disease is considered an auto-immune disorder. It is also classified, however, as a disorder of malabsorption – reduced absorption of nutrients. Malabsorption accounts for the primary symptoms of celiac disease. There is a genetic component to this disorder and thus can sometimes be found in family members. Approximately 10% of first degree relatives (parent, sibling, child) may develop celiac disease, especially in people of European origin. Symptoms can first appear in infants, children, or adults. Other disorders that can be associated with celiac disease include Type 1 diabetes, thyroid disease, dermatitis herpetiformis (a rare skin condition) on lupus.

What are the symptoms?

The function of the small intestine is to digest (break down) and absorb food, nutrients, vitamins etc. The microscopic structure of the small bowel involves fingerlike projections (villi) densely packed next to each other like the pile of a carpet. These villi increase the capacity of the intestine to absorb by 1,000 fold. The immune attack on the villi in celiac disease cause the villi to flatten, significantly reducing absorption of nutrients by the intestine.

The symptoms of celiac disease are primarily due to the defect in absorption of food, vitamins, and minerals (malabsorption). The amount of malabsorption can be mild or quite severe leading to no, minimal, or atypical symptoms in some patients and dramatic symptoms, such as progressive weight loss and diarrhea, in others. Symptoms typical of malabsorption of calories include weight loss, chronic diarrhea, bulky foul-smelling stool, stools that are oily or greasy appearing, flatulence (gas), and abdominal cramps. Malabsorption of more specific nutrients can cause other problems. For example, malabsorption of iron can lead to anemia. Poor absorption of calcium can cause osteoporosis (thinning of bones). In children, generalized malabsorption can cause short stature and poor weight gain. Fatigue, joint pain, seizures, poor dentition, and irregular menstrual periods can also occur.

How is celiac disease diagnosed?

The first step in diagnosing celiac disease is consideration of the diagnosis, so that appropriate testing can then be performed. Celiac disease may initially masquerade as other problems, such as irritable bowel syndrome, inflammatory bowel disease, intestinal infection, diverticulitis or chronic fatigue syndrome.

To make a diagnosis, an endoscopy is performed and small pieces of intestinal tissue are removed (biopsy) for examination under the microscope (for detailed description of endoscopy, refer to endoscopy/EGD article on this website under the "Procedures" section). Inflammatory cells, known as plasma cells and lymphocytes, are seen in amongst the small bowel cells. The fingerlike projections of small intestinal cells (villi) become damaged and flattened. This appearance under the microscope is typical of celiac disease.

Specific blood tests can also help support the diagnosis. Anti-endomysial and anti-gliadin antibodies and anti-reticulin antibodies are usually elevated in these patients. Blood levels of anti-endomysial antibody levels correlate with response to treatment, decreasing in patients compliant with therapy.

Treatment

The main treatment is to avoid eating food that contains gluten. Symptoms usually improve rapidly and the villi return to a normal structure within a few months. This diet is a lifelong and absolute commitment. Eating only a small bite of gluten-containing food can stimulate the immune response damaging the intestine. A small percentage of patients have "refractory celiac sprue" and do not respond to a gluten- free diet and require further therapy with an immunosuppressive agent (steroids and others).

A Gluten-Free Diet

A gluten-free diet involves avoiding all foods that contain wheat, rye and barley. Pure oats are safe to ingest, however, they are sometimes contaminated with wheat products and could be a problem. The dietary limitations are significant, but nonetheless, patients with celiac disease can enjoy a diverse diet by following special recipes using potatoes, rice, soy or bean flour. Commercially available products (breads, pastas, etc.) are available. Patients learn to read labels of foods and medications looking for "hidden gluten."

Gluten-Free Diet Guide

Following are examples of foods that are allowed and those that should be avoided when eating gluten-free. Please note that this is not a complete list. People are encouraged to discuss gluten-free food choices with their GCGA physician or dietitian. Also, it is important to read all food ingredient lists carefully to make sure that the food does not contain gluten.

beverages

Allowed –Coffee, tea, carbonated drinks, U.S. made wine, rum, some root beer

Not Allowed – Malted milk, ale, beer, gin, whiskey, flavored coffee, herbal tea with malted barley

MILK

Allowed – Fresh, dry, evaporated, condensed milk; cream; sour and whipping cream; yogurt

Not Allowed – Malted milk, some commercial chocolate milk, some nondairy creamers

MEAT, FISH, & POULTRY

Allowed – Fresh meat, fish, poultry

Not Allowed – Prepared meats containing wheat, rye, barley, oats, tuna canned in vegetable broth

CHEESE

Allowed – All aged cheese (cheddar, Swiss, edam, parmesan, etc.), cottage cheese, cream cheese, pasteurized processed cheese, cheese spreads

Not Allowed – Cheese containing oat gum, some veined cheeses ( bleu, stilton, Roquefort, gorgonzola)

POTATO & STARCH

Allowed – White and sweet potatoes, yams, hominy, rice, wild rice, gluten-free noodles

Not Allowed – Regular noodles, spaghetti, macaroni, packaged rice mixes, seminola, spinach noodles, frozen potato products with flour added

CEREALS

Allowed – Hot cereals made from cornmeal, cream of rice, hominy, rice, puffed rice

Not Allowed – All cereals containing wheat, rye, oats, barley; bran; graham; wheat germ; durum; kaska; bulgar; buckwheat; millet; spelt

BREADS

Allowed – Special prepared breads using only allowed flours

Not Allowed – All breads containing wheat, rye, oat, barley, and grains listed above

FLOURS & THICKENING AGENTS

Allowed – Corn bran, cornmeal, corn starch, corn flour, potato flour, rice bran, rice flour, rice starch, soy flour, tapioca starch, bean and lentil flours, nut flours

Not Allowed – Wheat germ, bran, rye, oats, barley, buckwheat, spelt, quinoa, teff, kamut, millet , amaramth

VEGETABLES

Allowed – All plain, fresh, frozen, or canned vegetables; dried peas and beans; lentils; some commercially prepared vegetables

Not Allowed – Creamed vegetables, vegetables canned in sauce, some canned baked beans, commercially prepared vegetables and salads

FRUITS

Allowed – All fresh, frozen, canned, or dried fruits; all fruit juices; some canned pie fillings

Not Allowed – Thickened or prepared fruits; some pie fillings; raisins and dried dates that have been dusted with flour

FATS

Allowed – Butter, margarine, vegetable oil, nuts, peanut butter, hydrogenated vegetable oil, some salad dressings, mayonnaise, nonstick cooking spray

Not Allowed – Some commercial salad dressings, wheat germ oil, nondairy cream substitutes, most commercial gravies and sauces

SOUPS

Allowed – Homemade broth and soups made with allowed ingredients, some commercially canned soups, specialty dry soup mixes

Not Allowed – Most canned soups and soup mixes, bouillon and bouillon cubes with hydrolyzed vegetable protein

DESSERTS

Allowed – Cakes, quick breads, pastries, and puddings made with allowed ingredients; cornstarch, tapioca, and rice puddings; some pudding mixes, custard; ice cream with few, simple ingredients; sorbet, frozen yogurt, meringues, mousse, sherbets

Not Allowed – Commercial cakes, cookies, pies made with wheat, rye, oats, or barley; millet, amaranth, buckwheat, spelt, teff, quinoa, kamut, prepared mixes, puddings, ice cream cones, Jell-O instant pudding, cream fillings, products made with brown rice syrup

SWEETS

Allowed –Jelly, jam, honey, brown and white sugar, molasses, most syrups, some candy, chocolate, pure cocoa, coconuts, marshmallows

Not Allowed – Commercial candies dusted with wheat flour; butterscotch chips, flavored syrups, sweets containing malt/malt flavorings; some brown rice syrup, some corn syrup

MISCELLANEOUS

Allowed – Salt, pepper, herbs, herb extracts, food coloring, cloves, allspice, ginger, nutmeg, cinnamon, chili powder, tomato puree and paste, olives, active dry yeast, bicarbonate of soda, baking powder, cream of tartar, dry mustard, some condiments, apple cider, rice or wine vinegar

Not Allowed – Curry powder, dry seasoning mixes, gravy extracts, meat sauces, ketchup, mustard, horseradish, chip dips, most soy sauce some distilled white vinegar, instant dry baking yeast, some cinnamon, condiments made with wheat-derived distilled vinegars, communion wafers/bread, some alcohol-based flavoring extracts.

Related Sites and Additional Information

Celiac Disease Foundation, www.celiac.org

Celiac Disease and Gluten-Free Diet Support Center, www.celiac.com

Ener-G Food, http://www.ener-g.com or 1-800-331-5222

Links to gluten-free products, recipes, and more, http://www.panix.com/~donwiss

Dietary Specialties, 1-800-544-0099