Originally published in The Ottawa Citizen December 2, 2003
Original Title: Wasting away on a full stomach

Part I – Don’t wait to deal with heartburn pain

Richard (not his real name) was a happy one year-old infant. After his first birthday he developed bloating and diarrhea and lost weight. His growth slowed. This condition persisted for months.

His mother, suspicious about a food-related condition, maintained a food diary. She noted that bread and cereal seemed to make him worse. A preliminary diagnosis of celiac disease (sprue or gluten-sensitive enteropathy) was made and was subsequently confirmed by a biopsy of the small intestine.

Reports of celiac disease began in the late 19th century. However, it was not until the mid 20th century when the removal of wheat and wheat products from the diet led to dramatic improvements. Celiac disease occurs when the protein gluten, found in wheat, stimulates a complex series of immune system events. These events produce an antibody that attacks the small intestine (an autoimmune reaction) compromising its ability to absorb nutrients. Certain autoimmune diseases like lupus and rheumatoid arthritis among others are associated with celiac disease.

Celiac disease affects one in 250 people. Some do not manifest any gastrointestinal symptoms but tend to have other problems like chronic fatigue, chronic diarrhea, unexplained weight loss, short stature, epilepsy and infertility.

If someone has a first-degree family member with celiac, his/her risk of developing celiac increases by ten to twenty per cent. Seven per cent of type 1 diabetics will also have celiac disease.

Celiac disease usually begins in infancy. Infants typically develop failure to thrive, bloating and abdominal distention, diarrhea, developmental delay and occasional severe malnutrition. Left undiagnosed, the condition can become a medical emergency.

The effects of celiac disease tend to be less severe in later childhood. Indeed, older children may end up with brittle teeth due to enamel breakdown or remain short for their age as the only signs of the disease.

Women comprise 75 per cent of new adult celiac disease cases. Common digestive system symptoms include diarrhea, constipation, bloating, gas and burping. They may experience chronic fatigue, fibromyalgia-like symptoms, mouth ulcers, stomach ache, acid reflux and heartburn and bone pain.

About ten per cent of adults will develop an intensely itchy red rash with tiny bubbles or vesicles that look like herpes on the buttocks, knees, back and elbows. This rash, dermatitis herpetiformis, can be misdiagnosed as a form of psoriasis or eczema.

Iron is absorbed by the small intestine. Iron deficiency anemia is commonly found in about half of the new cases of celiac disease because of the damage to the small intestine. This damage can also cause intestinal bleeding in about 50 per cent of patients too. Vitamin B12 and folic acid deficiency can also occur.

The diagnosis of celiac disease can be made on the basis of a blood test. This test looks for the antibodies that attack the intestine. The most accurate test is the IgA antiendomysial antibody test.

Many of the complications of the disease relate to the lack of nutrient absorption in the small intestine. The lack of calcium and vitamin D absorption can lead to a reduction in bone calcium ranging from mild loss (osteopenia) to severe loss (osteoporosis).

Nerve and brain damage may occur because the celiac-created antibodies (autoantibodies) attack the arteries of the brain. Calcium may deposit in the brain tissue potentially leading to epilepsy. Other nerve damage includes an inability to maintain posture and peripheral neuropathy (reduced sensation in the lower legs and feet).

Untreated patients are at risk for two forms of cancer, a leukemia called T-cell lymphoma and bowel adenocarcinoma. Proper life-long treatment and control of celiac disease will reduce this risk to that of the general population.

It is imperative to have a dietician design an appropriate diet. Completely removing gluten and its related proteins, found in wheat, barley and rye, is the only means to control the disease. The disease’s complications can be prevented or reversed with the addition of iron, folic acid, calcium and vitamin D supplements to the gluten-free diet.

Rice, corn, maize, flax, quinoa, tapioca, potato, amaranth, and other grain substitutes, such as nuts and beans, are safe. Pure oats are considered safe in small quantities but commercial oat products may contain wheat and other “impurities”

Fruits, vegetables, meats, and most dairy products are safe to eat. Specialty stores sell gluten-free breads, cereals, cookies and chips.

Consult your family doctor if you have chronic fatigue and diarrhea, unexplained weight loss, irritable bowel syndrome, iron deficiency anemia, epilepsy, short stature, infertility, a medical history of thyroid disease or type I diabetes or a family history of Celiac disease. This is another of the “silent” diseases out there that can be effectively treated.

Richard has followed a gluten-free diet for ten years. He remains in good health and lives a normal kid life.

For more information:
Canadian Celiac Association: http://www.celiac.ca/
Celiac Canada: http://www.penny.ca/Celiac-canada.htm

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© Dr. Barry Dworkin 2003