Celiac disease is being seen with greater frequency likely related to increased awareness, although there may be a rise in the number of cases related to environmental factors. It is a condition that most commonly causes diarrhea and abdominal discomfort, but also frequently presents with weight loss, fatigue, anemia and liver test abnormalities. Celiac disease is a common cause of abnormal liver tests and it should be thought of whenever there are no other explanations for these abnormal liver tests, especially in young and middle-aged people with gastrointestinal symptoms or weight loss.
Celiac disease is an autoimmune disorder that is induced by the intake of the protein gluten. Gluten is a derived from wheat, barley and rye and the intake of foods made from any of these products will worsen symptoms. Celiac disease affects approximately one percent of Americans (3 million people). Unlike many other conditions, this condition shows no predilection for any particular group of people and it can be diagnosed at any age. It is commonly seen in people whose ancestry hail from Europe, the Middle East, Asia, Australia, North America, South America and North Africa.
The protein gluten induces a reaction in the first portion of the small intestine or duodenum so most people will have symptoms making them think of the gastrointestinal tract. The initial presentation of celiac disease is highly variable and symptoms may be mild or quite severe. Children usually complain of diarrhea, bloating, vomiting, irritability, or even constipation. Many children are diagnosed when they are noted not to gain weight as would be expected for their age. Adults typically complain of diarrhea with or without the presence of abdominal pain or bloating, although these symptoms may be present in less than half of patients with the disease. In adults, women are more commonly affected. Celiac disease is also associated with lymphocytic colitis, a disease of the colon which can cause diarrhea, abdominal pain and weight loss. In addition to complaints related to the gastrointestinal tract, celiac disease may cause symptoms and signs related to other organ systems.
Common presentations in adults include anemia, osteoporosis, neurological complaints, rash and abnormal liver tests. Many patients with celiac disease were previously diagnosed with the irritable bowel syndrome and therefore the correct diagnosis was often delayed. Celiac disease is more common with people with diabetes.
The first step in the evaluation for celiac disease is to obtain blood tests for specific antibodies associated with celiac disease. The definitive diagnosis is made by endoscopy and biopsy of the small intestine. There are features seen on biopsy with are characteristic but not definitive for celiac disease. If typical endoscopic features are not seen, it may be a good idea to perform a capsule endoscopy to evaluate more of the small intestine. Ultimately, diagnosis of disease depends upon response to a gluten-free diet and in those patients with classic symptoms but a normal endoscopy, a gluten-free diet should be recommended.
The treatment of celiac disease is a gluten-free diet for life. The vast majority of people with this condition will respond to the change in diet. In years past, this diet was very difficult to follow but nowadays, most supermarkets and many restaurants offer gluten-free selections. The most common reason for recurrence of symptoms is dietary indiscretion. Untreated disease or prolonged dietary indiscretion places patients at risk for developing small intestinal cancer, small intestinal lymphoma and esophageal cancer.