What is Celiac Disease?
Wheat and other grains are made up mostly of starch. About 10-15% of wheat is made of gluten (gliadin), which is the protein portion. Other grains have similar proteins, such as barley (hordeins) and rye (secalins). These proteins are not entirely broken down by our stomach acid and can cause an intense immune reaction, an allergic reaction of sorts, with resulting inflammation in the small intestine.
A person can react to the wheat (wheat intolerance), the gluten portion (gluten intolerance) or to gluten after it is modified to a more toxic molecule by an enzyme in the gut wall, called tissue transglutaminase (true celiac disease). Wheat or gluten intolerance will simply cause an immune reaction leading to inflammation in the gut and throughout the body. Celiac disease also leads to the production of a specific antibody that attacks the lining of the gut wall, eventually destroying the lining. These distinctions are confusing to doctors and patients, yet critical in managing the conditions properly.
The result of the inflammation in the classic case causes gut related symptoms such as diarrhea, gas, heartburn, abdominal pain and bloating. This is fairly obvious to recognize and gives cause to consider the diagnosis. However, most people do not have this classic set of symptoms, which is why celiac disease is so under-diagnosed.
Tricky aspects of Celiac Disease
There are three other areas where celiac disease can cause problems: malabsorption, systemic inflammation and autoimmune disease, and cancers.
After damage to the small intestine, there can be problems absorbing vitamins, minerals and nutrients. This includes calcium, magnesium, iron, vitamins B12 and folate, the fat soluble vitamins D, E and K, as well as nutrient proteins. These deficiencies are the cause of many conditions caused by celiac, such as osteoporosis, anemia or muscle wasting.
Neurological conditions caused by celiac disease may include numbness or tingling in the hands and feet, balance problems, migraines, and even seizures or dementia. This is again due to poor absorption of vitamins such as B12 and B6, calcium, and magnesium. It is also due to the inflammation and the autoimmune process attacking healthy nerve tissue.
Depression is commonly associated with celiac disease, for uncertain reasons. It may simply be a reaction to the stress of dealing with a chronic illness or a gluten-free diet, but research also points to underlying causes such as poor absorption of folic acid or the inflammation causing changes in brain chemistry. We have noted this last area as we do a lot of work testing inflammatory chemicals called cytokines and also measure the associated changes in brain neurotransmitters. When we treat the underlying inflammation the brain chemistry often returns to balance. Symptoms such as depression, anxiety or fatigue then resolve.
If you have a persistent rash consisting of recurring blisters or scab-like lesions it may well be a special condition called dermatitis herpetiformis, found only with celiac disease. It is likely this rash has fooled doctors leaving the patient with no relief until they eliminate gluten from the diet. A skin biopsy next to the lesion is the best way to diagnose this condition as blood tests for celiac are often negative in this case.
Infertility can be a problem in celiac disease, noting that women and men are affected. If you are having trouble getting pregnant or having miscarriages, consider celiac disease as a culprit.
People with celiac are prone to get diabetes, due to the common genetics found in both diseases. Similarly, autoimmune diseases such as low thyroid, adrenal, lupus, MS and rheumatoid arthritis are more common in patients with celiac, just to name a few. There is increasing suspicion that celiac may play a role in fibromyalgia, and mental conditions such as ADHD, autism and schizophrenia.
Lastly, in patients with celiac disease, there is a significant increase in cancer, including lymphoma, melanoma, and cancer of thyroid, intestine, and esophagus. Avoiding gluten and monitoring for these conditions is part of celiac disease management.
The elimination / challenge diet is a simple way to see if you have problems with wheat, barley, rye or all three (which would imply issue with gluten). You can simply eliminate all gluten from the diet for several months and see how you feel. Then “challenge” with gluten products and see if symptoms return. You might do fine with barley and rye, suggesting more wheat intolerance. If all three bother you then it would be gluten intolerance or celiac disease proper.
The elimination diet alone can’t distinguish true celiac disease from gluten intolerance. For that, a biopsy of the small intestine is still the gold standard, showing damage to the lining of the gut. This is a relatively simple procedure done by a specialist with an endoscope. This seems a bit invasive, but before committing to a life of gluten avoidance, it is worth considering. It also confirms the possible conditions, noted above, that might appear along with celiac disease, and that is baggage worth knowing about.
Blood tests are often all that is necessary to sort out the diagnosis. One can simply measure the IgG and IgA antibodies against wheat (wheat intolerance), against gluten (called anti-gliadin) and against tissue transglutaminase (called anti-tTG). These tests are not perfect, and there are conditions which will cause false positive results. The most accurate blood test for celiac disease is IgA endomysial antibodies (EMA) which is almost 100% specific, meaning if the test is positive, it is about 100% likely you have the disease. It is also 90% sensitive, meaning the test is positive in about 90% of people with the disease. Many doctors consider EMA equal to the biopsy.
People with grain or gluten intolerance, may eat to tolerance, meaning a little here and there might not cause problems. With true celiac disease however, gluten should be avoided completely and forever. This is not easy in the modern world as gluten is found is so many products. But, it has gotten much easier with lots of gluten-free cookbooks and grocers carrying a wide variety of gluten-free products.
If you suspect possible problems with grain or gluten, simply get tested. Seek a knowledgeable professional to help with diagnosis and treatment. For a deeper dive into celiac disease I recommend reading “Celiac Disease” by Dr Peter Green.
Scott Rollins, MD, is Board Certified with the American Board of Family Practice and the American Board of Anti-Aging and Regenerative Medicine. He specializes in bioidentical hormone replacement for men and women, thyroid and adrenal disorders, fibromyalgia and other complex medical conditions. He is founder and medical director of the Integrative Medicine Center of Western Colorado (www.imcwc.com) and Bellezza Laser Aesthetics (www.bellezzalaser.com). Call (970) 245-6911 for an appointment or more information.