Celiac Disease

Celiac disease is a condition in which the immune system responds abnormally to a
protein called gluten (or gliadin), which can cause damage to the lining of the small
intestine. Gluten is found in wheat, rye, barley, and a multitude of prepared foods.
Celiac disease is also known as gluten sensitive enteropathy, celiac sprue, and
nontropical sprue.

The small intestine is responsible for absorbing food and nutrients. Thus, damage to the
lining of the small intestines can lead to difficulty absorbing necessary nutrients; this
problem is referred to as malabsorption. Although celiac disease cannot be cured, it can
be successfully treated by complete avoidance of gluten. Celiac disease can occur in
people of any age and it affects both genders.


The symptoms of celiac may vary from one person to another. In its mildest form, there
may be no symptoms whatsoever. Even in people who have no symptoms, there may
be evidence of malabsorption on laboratory testing. As an example, a low blood count
(anemia) may develop as a result of decreased absorption of iron. Early on, anemia may
cause no noticeable problems.

Others people have more bothersome symptoms, including diarrhea, weight loss,
abdominal discomfort, excessive gas, osteoporosis, and other problems due to
deficiencies of specific vitamins and nutrients.

Some conditions are more common in people with celiac disease, including: Dermatitis
herpetiformis (a specific form of rash), type I diabetes, thyroid problems (usually
hypothyroidism, an underactive thyroid), arthritis, and mild liver problems.


It is not clear why some people develop celiac disease. Genetic factors are clearly
important since celiac disease occurs primarily in certain groups of people, especially
whites of northern European ancestry. People who inherit specific genes that regulate
the immune response (HLA DQ2 and HLA DQ8) have a higher risk of celiac disease than
people without these genes. However, other factors are also important since only a
minority of individuals who have the DQ2 or DQ8 markers actually develop celiac


Celiac disease, especially early on, can be difficult to diagnose because the signs and
symptoms may be similar to other conditions. Fortunately, testing is available that can
distinguish celiac disease from other disorders.

Blood tests ‐ Several blood test are available that determines presence of antibodies
(proteins) that become elevated in most people with celiac disease. The main antibody
tests are Endomysial antibody (IgA EMA) and tissue transglutaminase antibody (IgA

Before having these tests, it is important to continue eating a normal diet, including
foods that contain gluten. Avoiding or eliminating gluten could cause the antibody
levels to normalize, becoming falsely negative and missing the diagnosis. Over 90
percent of people with untreated celiac disease have elevated antibody levels.
Small intestine biopsy ‐ If the blood tests are positive, the diagnosis is usually confirmed
by examining a small sample of the intestinal lining with a microscope. The sample
(called a biopsy) is usually collected during an upper endoscopy, a test that involves
swallowing a small flexible instrument with a camera. The camera allows a physician to
examine the upper part of the gastrointestinal system and remove a small piece
(biopsy) of the small intestine. The biopsy is not painful. In people with celiac disease,
the lining of the small intestine has a characteristic appearance when viewed with a
microscope. Normally, the lining has distinct finger‐like structures, which are called villi.
Villi allow the small intestine to absorb nutrients. The villi become flattened in people
with celiac disease, reducing the area that is functioning to absorb nutrients, causing
malabsorption. Once gluten is removed from the diet, the villi can regenerate a normal

One way to determine if the gluten free diet is working is to monitor the levels of
endomysial and tissue transglutaminase antibodies in the blood. The levels should
decline on the gluten‐free diet, which indicates that the diet has been effective.
Testing for malabsorption ‐ Patients with celiac disease are often tested for nutritional
deficiencies. Common tests include a blood count to detect anemia and low levels of
iron, folic acid, or vitamin B12, calcium, vitamin D, or vitamin K. Testing for bone
loss/osteoporosis with a DEXA (dual energy x‐ray absorptiometry) scan to measure the
density of bone is performed.


Consequences of malabsorption ‐ People with untreated celiac disease can develop
anemia, bone loss, and vitamin deficiencies.

Lymphoma— Cancer of the intestinal lymph tissue (lymphoma) is an uncommon
complication of celiac disease. Avoiding gluten can usually substantially reduce the risk
of this complication.


Gluten free diet ‐The cornerstone of treatment for celiac disease is complete
elimination of gluten from the diet. Patients who are malnourished because of the
disease may also need nutritional supplements.

Maintaining a gluten‐free diet can be challenging and requires significant dietary
adjustments. Gluten is contained in the most commonly consumed grains in the
Western world (wheat, rye, and barley) and is included as an additive in a large number
of prepared foods. Complete gluten avoidance is imperative since even small amounts
can aggravate and activate the disease.

Celiac diet ‐
* Foods containing wheat, rye, and barley should be strictly avoided.
* Soybean or tapioca flours, rice, corn, buckwheat, and potatoes are safe.
* Read labels on prepared foods and condiments. Additives such as stabilizers or
emulsifiers may contain gluten.
* Dairy products may not be well tolerated initially since many patients with celiac
disease can have secondary lactose intolerance. After starting a gluten free diet and
with healing of the small intestine, many can then again enjoy milk products.
* Oats are safe, if pure. Oats are often processed near wheat and are only considered
safe for celiac patients if the package specifically indicates that the product is gluten
free and was processed in a gluten free facility.


Consultation with an experienced celiac nutritionist /dietician is recommended for
detailed guidance and take home materials. Many internet resources are available but
be diligent in seeking reputable sites for medically sound information. Celiac.org is a
comprehensive and reliable website.

Fortunately, life on a gluten free‐diet has become increasingly easier due to the public
recognition of gluten related problems. Many restaurants offer gluten free foods and
most grocery stores now have a wide variety of foods safe for patients with celiac.

Is gluten avoidance really necessary? – Yes!

The effects of celiac can be severe but in some are subtle but still real. Untreated celiac
can cause anemia, vitamin deficiency, osteoporosis, fractures, fatigue, liver problems,
and rarely small intestinal cancer. Even if there are no symptoms, these effects can be


Eliminating gluten requires a major lifestyle change for the person who is affected by
celiac disease, with obvious impact on their family. However, with time and practice, it
becomes easier to know which foods and ingredients contain gluten and what
alternatives are available.

Families also need to be aware of their increased risk of celiac disease. Thus, firstdegree
relatives (parents, brothers, sisters, children) of a person with celiac disease
should consider being tested.