Celiac disease or gluten enteropathy is a chronic intestinal disease characterized by diarrhea, steatorrhea and malabsorption, generated by gluten intolerance. Morphological element is the atrophy of jejunal mucosa and gluten-free diet leads to clinical and histological improvment of the disease. The condition is widespread in temperate climates and has a chronic evolution, with onset or exacerbation after consumption of wheat flour products.
Disease prevalence is between 10 and 30 cases per 100.000 inhabitants, and in the last 15-20 years, with typical forms of disease, who present with diarrhea, steatorrhea and malabsorption, have appeared latent form of gluten intolerance, which not necessarily lead to mucosa atrophy, but only to interstitial inflammation of the jejunal mucosa.
Celiac disease is a genetically determined condition that has a familial character, is 10 times more frequent in first degree relatives of people with celiac disease and 30 times more common in twins.
In celiac disease, exist in enterocytes a genetic deficiency of peptidases, which lead to sensitization of the enterocytes to alpha-gliadin, a component of gluten. Gliadin is found mainly in wheat and rye and less in barley and oats.
Prolonged contact of the enterocytes with undigested gliadin, will lead to a local immunologic conflict, through formation of immune complexes of gliadin and gliadin antibodies. These immune complexes are fixed on the intestinal mucosa, stimulates T-cell aggregation, leading in this way to the damage of mucosa with the loss of villi and proliferation of cryptic cells.
Interruption of eating gluten favors the restoring of chorionic epithelium, improving transit and malabsorption disorders, with the condition that the diagnosis should be put in the first 3 to 6 years after clinical onset of the disease. In advanced forms of disease, intestinal mucosa regeneration is extremely slow or absent.
Celiac disease may be symptomatic or asymptomatic and may occur at any age, often without diarrhea or steatorrhea.
If it is celiac disease with onset in childhood, the child does not experience symptoms until the introduction of pasta in the diet. Then begin to appear loose stools with foul smell and intestinal cramps. Appear anemia, edema and hypoproteinaemia.
In the adult form of celiac disease, gradually appear diarrhea, steatorrhea and malabsorption syndrome later. Usually patients presents diarrhea for years (3-6 stools / day) associated with abdominal discomfort and gurgling. The onset of diarrheal syndrome is often insidious,in childhood, but sometimes after age 20 to 30. Most often diarrhea occurs in 1 to 2 hours after a meal of pasta wheat, but other intolerances occur during celiac disease that are making difficult to diagnose it. Important elements are the clinical symptoms which are correlate with the consumption of wheat flour and symptom disappear at 2-3 weeks after their interruption.
There are asymptomatic forms celiac disease that is manifested by iron deficiency anemia, short stature, hypocalcemia and dermatological diseases.
Diagnosis is made mainly in two ways:
- serological: determining anti gliadin antibodies, anti endomisium antibodies and anti reticulin antibodies;
- biopsy: characteristic features are the flattening of intestinal villi.
Intestinal biopsy association with positive serology for celiac disease is the gold standard in terms of the diagnosis of celiac disease.
In terms of histological lesions are evident in the first portion of the intestine.
Determination of anti gliadin antibodies have a sensitivity of 80-90% of cases of celiac disease. These antibodies become undetectable during gluten-free diet.
Anti endomisium antibodies are very sensitive, over 90% of cases of celiac disease, these antibodies are present.
Determination of antibodies in celiac disease is a useful test, especially in familial and population screenings, and in epidemiological studies, but the test that always confirm celiac disease is the intestinal biopsy.
Other paraclinical examination that can be used in celiac disease are:
- determination of steatorrhea, which is daily between 7 g and 50 g in case of severe celiac disease;
- impaired intestinal absorption tests, such as D-xylose test;
- highlighting the malabsorption syndrome, either selective (iron, calcium, etc.), either global.
The prognosis depends on the time of diagnosis. In cases of undiagnosed celiac disease will appear gradually malabsorption, which will lead in severe cases to death. Another cause of death is the development of lymphoid tumors, especially intestinal lymphoma. Other cancers which are favored by celiac disease are esophageal cancer and small intestine cancer.
In cases of celiac disease diagnosed and subjected to a gluten-free diet, the evolution is favorable, with disappearance of diarrhea, steatorrhea and malabsorption.
- Dietary: Celiac disease can have a favorable evolution with a gluten-free diet. Wheat, barley, rye and oats will be removed from the diet. Is admitted the consumption of corn flour, rice flour and potato. Completely cure of celiac disease (in pathology exam lesions can not be detect ) in 3 to 5 years of a gluten-free diet, but favorable clinical response can occur from 3 to 6 weeks after starting the diet. Gluten-free diet is for life.
Supervision of compliance with diet can be done by dosing anti gliadin antibodies, which after a few months to a year of proper diet will be normal, but will increase again in case of stopping the gluten-free diet.
- Medications: When dose not appear a improvement of symptoms after eliminating gluten from the diet, because celiac disease is in an advanced stage, oral corticosteroids is recommended for a period of 4 to 8 weeks.