CELIAC DISEASE

In the second century AD, the distinguished Aretheus of Cappadocia, a Greek physician practicing in Rome, during his practice got to know many patients who presented with a strange symptomatology, which the Clinician minutely reported in his treatises on gastrointestinal diseases.

Specifically, the doctor noticed that some patients presented with violent bouts of diarrhea, with the emission of foul-smelling, almost white stools, and abdominal spasms and cramps so severe that they were unable to work.

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These symptoms recurred cyclically, especially when patients ate certain grain-based food.

Areteus, although short on modern scientific information, guessed that the problem was due to malabsorption of food, resulting in incomplete digestion.

The Physician described the condition as κοιλιακός (koiliakòs, meaning 'abdominal'), and branded it as incurable, with the means then available to his Medicine.

Again, the hunch about the prognosis was right: celiac disease, also known as celiac disease, is still incurable.

Read this page to learn what celiac disease is, how it is diagnosed, and what can be done to treat it.

What is celiac disease?

Celiac disease is a gastrointestinal disorder of a genetic order, manifesting as an abnormal alteration in the absorption of gluten, which is a fairly sticky, water-insoluble agglomerate of protein found in cereals and their flours (wheat, barley, spelt, rye, etc.).

In the patient with celiac disease, even the smallest intestinal contact with gluten causes a very violent autoimmune reaction, which triggers an equally violent inflammation.

This results in intestinal spasms, abdominal cramps, and the onset of dramatic diarrheal discharges, which can last for days, during which time the patient becomes extremely weak and prostrate, pale and emaciated, essentially unfit for any work activity (exactly as Areteus of Cappadocia had already diagnosed over two millennia ago).

What are the causes of celiac disease?

The genetic causes of celiac disease, which, like all autoimmune diseases, is difficult to define etiologically, are not yet known.

The most widely accepted theory to explain the origin of this extreme gluten intolerance is one that predicts a correlation of genetic predisposition and certain environmental factors judged to be triggers.

Recent research has definitely confirmed suspicions of genetic inheritance of celiac disease, while investigations to establish the mechanism of intestinal wall inflammation upon contact with gluten are still ongoing.

At the clinical level, three triggers of celiac disease are now established and known:

• Genetic predisposition;
  
• Gluten-rich diet;
  
• Condition of mental and physical stress

These three conditions, believed to be essential to trigger symptomatology, explain how the condition is triggered at any age of life, not just in the pediatric stage.

Why does gluten trigger violent intestinal inflammation?

Celiac disease is not an intolerance toward gluten per se, but in one of its major components, namely gliadin.

When a patient with celiac disease ingests even a small amount of gliadin (just a few fragments of a cereal flour, for example), it is brought, in the normal gastrointestinal pathway of digestion, into contact with the villi of the small intestine.

Right there the inflammatory reaction is triggered: the T lymphocytes attack the gliadin, recognizing it as an unwanted and potentially dangerous foreign element, and begin to produce high amounts of cytokines.

In turn, cytokines cause gut wall cell death (apoptosis), with associated inflammation.

The intestinal response is very violent: intestinal cramps begin almost immediately, followed by violent spasms and the onset of diarrheal discharges, with the emission of yellowish (tending to white) stools with a typical pungent, foul-smelling odor.

What are the symptoms of celiac disease?

Although the origin of celiac disease is always the same (extreme intolerance to gluten), there are various symptomatic categories, which can differ greatly from each other.

Thus, at present, at the clinical level, we have these symptomatic manifestations:

Symptomatic (or typical) celiac disease

The classic form of celiac disease, manifested by violent bouts of diarrhea and the emission of extremely foul-smelling whitish-colored stools, often particularly fatty.

In accompaniment, ai appreciate extreme weakness of the subject, emaciated features, weight loss, inability to work due to extreme exhaustion.

These symptoms occur exclusively in the case of ingestion of food with the presence of gluten, or contaminated with it, even in a small part;

Atypical celiac disease

Atypical form of celiac disease that does not necessarily involve intestinal disorders of the typical form, but may manifest lassitude and fatigue, anemia, various neurological disorders, and, especially in women, osteoporosis.

Its diagnosis is complicated by the fact that such symptoms are common and shared with other conditions, neurological in nature;

Silent celiac disease (or asymptomatic celiac disease)

Form of celiac disease often referred to, incorrectly, as the 'healthy carrier', because although anti-gliadin antibodies and intestinal villus atrophy are present, the patient does not manifest any symptoms;

Potential celiac disease (or latent celiac disease)

In this form of celiac disease, the symptoms of the typical form have not yet been manifested, but the antigliadin antibody test is positive.

The eruption of symptoms is possible at any time, which is why the patient is urged to start dietary therapy as soon as possible, just as if he or she had already developed the typical form.

It should be remembered that whatever the form of the symptomatology of celiac disease, some elements are always present, such as: positive anti-gliadin tests and atrophy (flattening) of intestinal villi.

It is precisely this damage to the villi that can lead, in the long run, to problems with absorption of nutrients, particularly fat-soluble vitamins (A,D,E and K) as well as malabsorption of iron and the essential vitamins B9 and B12.

In turn, this iron and vitamin K deficiency can lead to difficulty in wound clotting.

Then there is all the proctological symptomatology associated with frequent diarrheal discharges, which often occurs over the long term in patients who do not follow the therapeutic diet scrupulously, such as: hemorrhoidal prolapse, proctitis and anitis, anal fissures, and, in general, periodic inflammation of the anal and peri-anal area.

How is celiac disease diagnosed?

The diagnosis of celiac disease is based on specific blood and instrumental tests: therefore, a simple clinical examination is not enough, but the presence of anti-gliadin antibodies and intestinal villous atrophy must be ascertained.

This is done with specific antibody tests:

• Anti-gliadin antibodies (AGA);
  
• Anti-endomysium antibodies (EMA)
  
• Anti-transglutaminase antibodies (TGA)

Genetic predisposition to celiac disease, on the other hand, is possible through a very quick blood test, which assesses the presence of the HLA DQ2/DQ8 genes responsible for genetic transmission of the intolerance.

A possible positive result indicates genetic predisposition but not necessarily certainty of the disease, while a negative result indicates no possibility of developing celiac disease in the future.

Blood tests are then mandatorily correlated by a gastroscopy with biopsy, which is essential to ascertain the status of the intestinal villi.

What is the treatment for celiac disease?

In the current state of Medicine, celiac disease shares with other genetic disorders the impossibility of cure.

This means that no drugs are available that can inhibit the autoimmune reaction of lymphocytes to the passage of gluten into the intestine, nor are surgical protocols also available.

The only possible therapy is the one already known in ancient times, and that is dietary therapy.

Which is basically based on always avoiding the ingestion, especially accidental ingestion, of even microscopic amounts of gluten.

This means that patients with celiac disease must follow a strict diet, free of any wheat derivative, which they must maintain for life.

Fortunately, nowadays, there are a huge number of companies that produce gluten-free foods that are safe and also taste good and have the right nutritional values, which patients with celiac disease can buy without worry even in ordinary supermarkets.

A zero-gluten diet, if protracted scrupulously, provides the celiac patient with a normal, trouble-free life comparable to that of another healthy person.

Of particular importance is proper behavioral management for the patient with celiac disease: almost always, acute episode of diarrheal attack are the result not of deliberate misfeeding but of incidents with contaminated food, in most cases after a lunch or dinner out.

It should be remembered that even very small amounts of gluten are sufficient in a patient with celiac disease to trigger the violent immune response, and this often happens when eating accidentally contaminated food.

But are gluten-free products better than regular ones, even for non-celiac patients?

No, in the most absolute way.

Gluten-free products are specific, therapeutic we can say, products exclusively designed for patients with celiac disease.

They are not 'better' or 'worse' than gluten-containing foods: they are an indispensable resource for those with established celiac disease who cannot ingest gliadin.

Gluten is not, per se, a harmful element for healthy humans: a healthy intestine can safely break it down thanks to the appropriate enzymes, so its presence is not deleterious and does not, per se, initiate celiac disease (as unfortunately everyone still believes).

Celiac disease cannot occur where there is no genetic predisposition, regardless of whether the diet is low in gluten or not.

Unfortunately, in recent times, health and medical misinformation has passed off gluten-free products as potentially healthier than common foods with gluten.

This is part of the broader phenomenon called 'Health Halo', which peddles products and therapies of unfounded scientific rationale (such as hydrocolon therapy, pressure therapy or vegan diets) as 'healthy', when in fact there is no objective medical evidence to call them such.

It should be remembered that the gluten-free diet is very expensive, challenging, and should by no means be taken as a fad: it is an essential therapy if and only if you have celiac disease, while it is completely negligible if you are healthy.

For non-pathological individuals with no detected allergies, simply stick to a varied and balanced, omnivorous diet with the right balance of carbohydrates, fiber, vitamins, protein and, of course, water.

Which specialist should you go to if you suspect celiac disease?

Celiac disease is a condition that must be diagnosed exclusively by a Physician, who is usually a Gastroenterologist or Colonproctologist.

These two health professionals are in fact the appropriate specialists to prescribe specific examinations and monitor the patient's health status over time, and should therefore be preferred at the diagnosis stage.