Celiac Disease

Symptoms, Causes & Treatment

Celiac disease is an auto-immune condition caused by an abnormal immune response to gluten, the major storage protein found in wheat, barley, rye (and possibly oats).

Gluten is made up of two main groups of proteins – gliadins and glutenins. The gliadin fraction reacts with an enzyme in the digestive tract (tissue transglutaminase), resulting in inflammation and damage to the tiny hair-like projections (villi) that line the wall of the intestine.

When these villi become damaged and flattened, the surface area of the bowel available for nutrient absorption is markedly reduced.

Celiac disease is one of the most under-diagnosed, yet most common, chronic diseases, affecting around 1 in 70 Australians. It can develop at any stage of life and affects women twice as frequently as men. It is thought that 90% of celiac disease is undiagnosed and obvious signs may not become apparent for years.  Therefore the prevalence is likely much higher than 1 in 70.  Most people report feeling better on a gluten free diet.

If left undiagnosed, it can lead to the possibility of severe consequences such as intestinal damage, anaemia, osteoporosis, infertility, miscarriage, depression, dental cavities, and an increased risk of bowel cancer due to chronic inflammation of the bowel wall.

When gluten is ingested, transglutaminase enzyme acts on it to break down the gliadin into gliadin peptides, known as deamidation. [Transglutaminase cannot completely break down gliadin, therefore no one is able to digest gluten completely]. In susceptible individuals, antibodies form to either the tissue transglutaminase (classic celiac) or to the deamidated gliadin peptides (DGP). These antibodies activate B and T cell inflammatory processes, causing damage to the villi cells and compromised absorption.

Causes of Celiac disease

• Genetic predisposition
• Caucasians of European descent
• Intestinal dysbiosis and increased intestinal permeability
• Viral infection (e.g. gastroenteritis): may be a triggering factor in genetically susceptible people
• Early exposure to gluten
• Hybridisation of wheat (increased gluten content)

Signs and symptoms of Celiac disease

The clinical presentation of celiac disease is markedly varied and depends largely on age. The classic presentation (below) is usually seen only in children and represents the ‘tip of the celiac iceberg’.

Many people with celiac disease are asymptomatic. There is no correlation between symptoms and bowel damage, so even if asymptomatic, damage to the small intestine may still occur when gluten is ingested.

Classical symptoms include:

• Diarrhea with loose, pale, fatty, malodorous stools
• Failure to thrive (in children): short stature and weight loss
• Abdominal pain, cramping and bloating
• Vomiting
• Fatigue
• Mouth ulcers

Adults with celiac disease may be asymptomatic or present with:

• Abdominal pain
• Diarrhea (presents in 50% of adults with CD)
• Constipation
• Irritable bowel syndrome
• Bloating
• Excessive flatulence
• Gastro-esophageal reflux disease (GERD): CD sufferers are significantly more prone to GERD symptoms so it may be prudent to screen GERD sufferers for celiac disease, especially if there is a family history of CD, they present with other symptoms of CD, or they respond poorly to initial therapy

Extra-intestinal symptoms

• Anemia
• Acute arthritis (occurs in up to 25% of patients with CD)
• Dental enamel hypoplasia (occurs in 20-70% of patients)
• Dermatitis or other skin disorders
• Fatigue
• Mood disorders: depression, anxiety, irritability
• Peripheral neuropathy
• Migraine
• Infertility
• Osteoporosis
• Epilepsy
• Chronic mouth ulcers
• Obesity

With long-standing disease, symptoms of vitamin and mineral deficiencies will occur, which may be the first sign of CD in some people. In particular:

• Vitamin D deficiency: rickets, osteoporosis
• Vitamin K deficiency: tetany, bleeding disorders
• Iron and/or folate deficiency: anemia

In addition, other auto-immune diseases, such as autoimmune thyroiditis and Type 1 diabetes, are often present.

Investigations and Medical Testing for Celiac Disease

• Celiac serology: measures specific antibodies in blood. Tissue transglutaminase antibodies is thought to be the most sensitive and specific (95%) test. Many tests in Australia at present are unreliable as they only test a small number of gliadins and transglutaminases, between 2 and 4 and only testing IgA not IgG.
• Food Intolerance Testing

• Gene testing (HLA gene): useful when other tests are unclear. Not dependent on gluten ingestion. Nearly everyone with CD has some variant of the HLA gene; however, the presence of the gene does not guarantee the individual will develop CD.

TREATMENT STRATEGY FOR CELIAC DISEASE

• Remove all forms of gluten from the diet: this is currently the only effective treatment for celiac disease. Avoidance must be complete and life-long. Once gluten is removed, the small bowel lining steadily repairs itself and the absorption of nutrients from food returns to normal.
• Investigate  the gut microbiome and address dysbiosis, bacterial overgrowth, SIBO, parasites etc
• Identify and eliminate other food allergens: cross-reactivity is common with other non-gluten foods
• Support digestive function
• Reduce gut inflammation
• Repair and heal gut lining
• Address nutritional deficiencies

Diet plan guidelines for Celiac Disease

• Strict gluten-free diet: eliminate wheat (including bulghur, couscous, spelt, durum, kamut, seitan, semolina, wheat starch and wheatgrass), rye, barley and oats. 

Oats remains controversial: the ‘gluten’ fraction of oats is avenin, which has a slightly different amino acid make-up to the gluten found in wheat, rye and barley.  Clinically, at our Perth clinic of Advanced Functional Medicine we find oats do flare up a large number of patients so we advise to remove oats from the diet along with other wheat and gluten sources

• Substitutes for wheat include rice, corn, tapioca, buckwheat, quinoa, potatoes, millet, arrowroot and amaranth.  Note: many ‘gluten-free’ products (e.g. breads) are based on highly refined starches and are not necessarily healthy substitutes for wheat products and are common cross reactivity sources that cause flare ups.
• Remove other known food allergens: may need elimination diet
• Alcohol: all alcohol, except beer, is gluten free. Some gluten-free beer is now available commercially.
• We recommend initially following an Autoimmune Paleo Diet (AIP diet) until symptoms has subsided and gut investigation and repair has been achieved.  Following this, reintroduction of some foods moving back toward a standard paleo type diet is often recommended at our clinic.

Supplements that support Celiac Disease

• Digestive enzymes – stimulate digestion
• Glutamine – promote gut repair
• Slippery elm – protection of intestinal lining
• Probiotics – Replenish health bowel flora
• Multivitamin and mineral: to replenish nutrients
• Glutenflam – digestive aid to specifically assist with breakdown of gluten

Herbal Medicine treatment that supports Celiac Disease

• Nutritives: alfalfa, nettles
• Gut mucosa repair: goldenseal, slippery elm, licorice, aloe vera
• Digestive stimulants: gentian, agrimony, ginger
• Immune support: echinacea, albizzia, baical skullcap

FUNCTIONAL MEDICINE TREATMENT OF CELIAC DISEASE

Celiac disease an extremely underdiagnosed disease.  Celiac disease sufferers are not able to tolerate gluten in all forms.  Most non celiac individuals however report doing better without gluten or feeling better with a greatly reduced gluten/grain intake. 

We currently use world class USA based testing from Cyrex laboratories for gluten intolerance and celiac testing.

At our Advanced Functional Medicine Perth clinic we have extensive experience with celiac disease and identify many food intolerances for both celiac and non-celiac individuals.  Numerous patients that we test have no idea that their body is mounting large numbers of immune antibodies due to various grains they are ingesting that is contributing to a wide range of non-specific symptoms such as brain fog and fatigue.

If you or a family member are suffering from celiac disease or suffer from suspected food intolerances we would love to hear from you, what are the most common offending foods?  How were you tested to be diagnosed with intolerances?  Have those intolerances improved over time with treatment?  Please write a comment below.

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