Celiac disease

Content

Introduction

Introduction

Celiac disease is a permanent inflammatory bowel disease triggered by the consumption of foods containing gluten (read the Buffalo), in genetically predisposed subjects (Video).

Gluten can cause a wide variety of disorders (symptoms), even of varying severity. In the classic form, the most frequent are:

  • diarrhea
  • abdominal bloating
  • abdominal pain
  • weight loss, as a consequence of intestinal malabsorption
  • slowing of growth in children

Celiac disease occurs when the body's defense system (immune system) mistakenly attacks the healthy tissue of the intestinal wall.

More specifically, the surface of the intestine is covered with millions of small finger-shaped growths, called villi, which have the function of increasing the surface useful for absorbing the nutrients introduced with food.

In celiac subjects, gluten activates the immune system which recognizes certain molecules in the intestine as harmful and reacts against them causing damage, inflammation and flattening of the villi. Thus, the disorders of celiac disease are determined.

Gluten

Gluten is a protein found in three types of cereals (read the Buffalo):

  • grain, of all kinds (read the Bufala)
  • barley
  • rye

It is present in foods that contain them, including:

  • pasta, pizza, bread, crackers, bread sticks
  • cakes, snacks
  • breakfast cereals
  • breaded meat and fish

It is also added to many foods as an additive during the industrial processing phase. In particular, in:

  • sauces
  • ready meals
  • ice creams
  • some types of yogurt

Even beer, produced from the fermentation of barley, must be avoided by celiacs.

Spread of celiac disease

According to data from the scientific literature, celiac disease affects about 1% of the general population globally. In Italy, therefore, there should be around 600,000 celiacs. As of 31/12/2018 the confirmed cases (diagnosed) were just over 214,000. In our country, in fact, there are less than 400,000 undiagnosed celiacs who, using gluten daily, present the symptoms (symptoms) of the disease and risk complications.

Celiac disease is more common among women (as many as 2 out of 3 cases concern women) and can develop at any age.

The data on the spread of the disease in Italy are described and updated annually in the Report to Parliament on celiac disease, edited by the Ministry of Health, which also contains a lot of useful information for celiacs. Further information on the gluten-free diet, food and local associations can also be consulted on the website of the Italian Celiac Association (AIC).

Symptoms

Symptoms

The symptoms (symptoms) of celiac disease can vary a lot. In milder cases, sufferers do not have any obvious discomfort and often discover that they are celiac by undergoing tests for other diseases.However, treatment is always recommended as the complications of celiac disease can also occur in these cases.

Common ailments (symptoms)

In the classic form, the most frequent symptom is diarrhea, caused by the body's inability to fully absorb nutrients (malabsorption).

Other common disorders (symptoms) are:

  • bloating in the belly (abdominal)
  • abdominal pain
  • weight loss
  • intestinal malabsorption
  • slowing of growth in children

Disorders (symptoms) of the atypical form

The classic form is increasingly rare, while confirmed (diagnosed) cases of the atypical form in adults are increasing. Among the disorders (symptoms) of the atypical form:

  • tiredness and fatigue, which may be signs of iron deficiency anemia or folate deficiency anemia
  • hair loss (alopecia)
  • weight loss for no other cause
  • recurrent ulcers and lesions in the mouth (recurrent oral aphthosis), loss of tooth enamel (hypoplasia)
  • recurrent abdominal pain
  • He retched
  • increased level of transaminases
  • menstrual cycle disorders
  • reduced stature
  • infertility, repeated miscarriages
  • pregnancy disorders
  • reduction in bone mass (osteopenia, osteoporosis)
  • tingling and numbness in the hands and feet, lack of muscle coordination (ataxia)

Herpetiform dermatitis caused by gluten

Dermatitis herpetiformis is a skin disease characterized by an eruption of blisters and blisters that cause intense itching. It is most frequently located in the lower back (lumbar region), elbows, knees.

It is also called skin celiac disease or skin because in these patients gluten, instead of causing intestinal inflammation, causes a reaction in the skin (skin).

Almost all patients respond perfectly to a gluten-free diet.

Causes

Causes

Celiac disease is caused by an abnormal reaction from the body's defense system (immune system) to gluten proteins, contained in foods such as bread, pasta, cereals and biscuits.

It is an autoimmune disease that occurs when the immune system attacks the cells and healthy substances of the body, mistaking them for harm and therefore produces antibodies to fight them.

The substance that triggers the reaction of the body's defense system is contained in gluten and is called gliadin. When introduced into the body through food, it causes inflammation of the bowel wall which, inside, is covered with millions of small finger-shaped growths, called villi. They have the function of increasing the surface that comes into contact with food and absorbs the nutrients contained in it.

In celiac disease patients, tissue inflammation flattens the villi, reducing their absorption capacity and causing symptoms of celiac disease.

Risk factors

It is not known why only 3% of people who have the genetic predisposition to celiac disease and consume gluten sooner or later develop the disease, nor why some have mild symptoms and others severe.

However, the following factors can play a role in the development of the disease:

Familiarity

Scientific research shows how celiac disease is strongly associated with different alleles (normal variations) of genes that affect, above all, the groups called HLA-DQ, responsible for the development of the immune system and transmissible to descendants.

First degree relatives (children, brothers / sisters, parents) of celiac sufferers have a risk equal to about 15% more, compared to the general population, of developing celiac disease.

Environmental factors

Certain factors, including digestive tract infections (such as a viral infection) during early childhood, are believed to play an important role in the development of celiac disease.

Recent studies have shown that neither the method of feeding (breast or formula) nor the age at which gluten was first introduced into the diet, for example during weaning, affect the risk of developing celiac disease. in childhood.

Autommune diseases

The presence of an autoimmune disease increases the risk of developing celiac disease by up to 10 times compared to the general population. Diseases associated with celiac disease include:

  • type 1 diabetes mellitus
  • autoimmune thyroiditis
  • Sjögren's syndrome
Diagnosis

Diagnosis

Currently, conducting tests on population groups that do not show any disorders (screening) to discover the possible presence of celiac disease is not justified; on the contrary, screening is recommended in so-called "at risk" people because they have suggestive symptoms or signs, have first degree relatives with celiac disease or suffer from autoimmune diseases or genetic diseases.

The tests that allow to ascertain (diagnose) celiac disease are:

  • blood tests
  • intestinal biopsy

Blood analysis

The tests are performed on a small amount (sample) of blood, taken from a vein in the arm, to determine the level of certain antibodies (anti-endomysus and anti-transglutaminase) present in the peripheral blood. These antibodies, in fact, are produced in cases where gluten is perceived by the body as a foreign and dangerous substance.

In the period prior to carrying out the blood tests, it is therefore recommended not to limit gluten in the diet, otherwise the results of the analyzes could be distorted.

In the event that the presence of these antibodies is found in the peripheral blood, it will be necessary to undergo an intestinal biopsy, an examination that allows you to check if the villi are damaged or atrophied. In some selected pediatric cases, celiac disease can be ascertained without resorting to intestinal biopsy.

Intestinal biopsy

The biopsy is performed by inserting a thin and flexible tube, equipped with a camera (endoscope) into the mouth of the person undergoing the examination, and making it arrive delicately in the small intestine. Before starting, the doctor may spray a local anesthetic into the throat to decrease sensitivity or administer a mild sedative to help relax.

Very small quantities (samples) of the mucous membrane of the small intestine are taken through the endoscope and then analyzed under a microscope to check if the signs of celiac disease are present.

In a selected pediatric population (level of anti-transglutaminase antibodies in peripheral blood over 10 times the limit of normal), it is possible to make a diagnosis without resorting to duodenal biopsy.

The Ministry of Health, in 2015, issued an update of the Guidelines for the assessment (diagnosis) and control over time of celiac disease, published in the Official Gazette no. 191 of 19 August 2015. The Guidelines include two diagnostic flow-charts, one for adulthood and one for pediatric age and are available at this link.

Post-diagnosis examinations

Once celiac disease has been ascertained (diagnosed), it is necessary to periodically carry out checks to check the quantities of autoantibodies, iron, folate and other substances present in the blood, which vary according to the level of inflammation.

Only in adults, after at least 18 months from the detection of the disease, it is recommended to perform a bone densitometry. The examination consists in undergoing X-rays that measure the amount of minerals present in the bone (bone density) to assess whether osteoporosis is present. A lack of nutrients and, in particular, calcium and vitamin D, caused by intestinal malabsorption can make bones weak and fragile (osteoporosis).

Therapy

Therapy

At the moment, the only cure available for celiac disease is a permanent and strict gluten-free diet. The complete elimination, and for life, of gluten from the diet allows the disorders caused by the disease to disappear and above all to avoid serious complications.

It is important that the gluten-free diet is balanced and varied. This is possible, on the one hand, thanks to the availability of naturally gluten-free foods such as, for example, meat, fish, eggs, vegetables, fruit and vegetables; on the other, thanks to the increased presence on the market of gluten-free foods specially formulated for celiac people.

Oat is a cereal allowed in the gluten-free diet, although before eating it you should be sure that it has not been contaminated by wheat and that it is a variety tested to be consumed by people with celiac disease. based on oats specially formulated for celiacs, present in the National Food Register of the Ministry of Health. The inclusion of oats in a gluten-free diet is not advisable before two years have elapsed from the detection of the disease.

The gluten-free (or gluten-free) diet

When you are sure you are celiac because the disease has been ascertained by a doctor, it is necessary to consult a specialist doctor and a dietician to be helped in the transition to a gluten-free diet and to be sure that it is balanced and contains all the nutrients you need.

People with celiac disease cannot eat foods containing barley, rye or wheat. Even a small amount of gluten, such as that contained in a spoonful of pasta or in a crumb of bread, can cause very unpleasant intestinal disorders. Repeated consumption of gluten can cause complications of varying severity.

Gluten is not essential in the diet and can be eliminated without nutritional deficiencies occurring. There are now several products on the market marked on the packaging by the wording "Gluten-free" - specially formulated for celiacs including pasta, pizza bases, flours, cakes, crackers and bread; and products with the wording "Gluten free" - suitable for celiacsamong which you can find ready made soups and plants, some sausages, ice creams, drinks.

It is very important to always check the labels of the foods you buy since many, especially processed ones, may contain gluten in additives such as, for example, the barley malt flavor and modified starch.

Finally, it is worth knowing that many foods, such as meat, vegetables, vegetables, legumes, potatoes and rice, are naturally gluten-free.

In case of uncertainty about foods that contain or do not contain gluten, you can consult the website of the Italian Celiac Association (AIC) which publishes useful lists (The ABC of the celiac diet).

Currently, in Italy and in the world, products that can be classified as gluten free are those that have less than 20 parts per million (ppm).

Herpetiform dermatitis

If you have dermatitis herpetiformis (an itchy rash that can be caused by "gluten intolerance), eliminating gluten from your diet should solve the problem. Sometimes, however, the healing process of the rash is more difficult. slow compared to the rate at which other ailments such as diarrhea and stomach pain are reduced; in these cases, the doctor may prescribe so-called oral medications immunosuppressantsto speed up healing.

Complications

Complications

Consuming gluten-containing foods, even in small quantities, can cause various complications in celiac people.
Potential long-term complications include:

  • refractory celiac disease
  • tumors
  • atrophy of the spleen

Refractory celiac disease

It is a rare form of celiac disease (less than 1% of all cases of adult celiac disease) in which the disorders (symptoms) continue to persist even after switching to a gluten-free diet.

If refractory celiac disease is suspected, a series of tests should be performed to verify that the symptoms (symptoms) are not caused by some other disease or by unconscious consumption of gluten. If the tests confirm that it is a refractory celiac disease, it will be necessary to consult a specialist in this disease.

Treatment options include steroid drugs and, in general, so-called immunosuppressive drugs capable of blocking the reaction of the immune system.

Tumors

Continued exposure to gluten by people with celiac disease increases the risk of developing bowel cancer and non-HodgKing lymphoma. On the other hand, for reasons yet to be defined, the risk of getting lung and breast cancer decreases.

Since age is in itself an independent risk factor for intestinal cancer, in celiac people the risk of developing this type of cancer also increases with advancing age.

It is also believed that the risk of developing cancer is greatest during the first year following the discovery of the disease, and then gradually returns to normal levels after switching to a gluten-free diet.

Hyposplenism

Celiac people with hyposlenism (decreased functioning of the spleen) are more prone to being affected by infections. For these reasons, it is advisable to undergo anti-pneumococcal and influenza vaccination as well as, where necessary, antibiotic prophylaxis.

Lactose intolerance

Celiacs are also more likely to develop lactose intolerance which consists in the lack, or in the "insufficient quantity," of the enzyme that digests the sugar present in milk (lactose) and products derived from it. Usually, it is an intolerance resulting from the atrophy of the villi which resolves after a few months from the start of the gluten-free diet.

Bibliography

Bibliography

Regulation (EU) n.609/2013 of the European Parliament and of the Council on foods intended for infants and young children, foods for special medical purposes and substitutes for the entire daily diet for weight control and repealing Directive 92/52 / EEC of the Council, Directives 96/8 / EC, 1999/21 / EC, 2006/125 / EC and 2006/141 / EC of the Commission, Directive 2009/39 / EC of the European Parliament and of the Council and regulations (EC ) n. 41/2009 and (EC) no. 953/2009 of the Commission

Implementing Regulation (EU) No. 828/2014 of the Commission, of 30 July 2014, relating to the requirements regarding consumer information on the absence of gluten or its presence to a reduced extent in food. Text with EEA relevance

Law 4 July 2005, n. 123. Rules for the protection of people with celiac disease. (Official Gazette No. 156 of 7 July 2005) Decree of 17 May 2016 of the Ministry of Health. "Supplementary health care for products included in the field of application of Regulation (EU) 609/2013 and for food products intended for celiacs and amendments to the decree of 8 June 2001"; Supplementary health care for products included in the field of application of regulation (EU) 609/2013 and for food products intended for celiacs and amendments to the decree of 8 June 2001. (Official Gazette No. 136 of 13-06-2016)

Decree of 17 May 2016 of the Ministry of Health. Supplementary health care for products included in the field of application of regulation (EU) 609/2013 and for food products intended for celiacs and amendments to the decree of 8 June 2001. (Official Gazette No. 136 of 13-06-2016)

Decree of 10 August 2018 of the Ministry of Health. Maximum spending limits for the supply of gluten-free products, as per article 4, paragraphs 1 and 2, of law no. 123, bearing: "Rules for the protection of people with celiac disease". (GU General Series n.199 of 28-08-2018)

Ministry of Health. Circular of 26 September 2018, n. prot. 0036901 on the terms of application of the Ministerial Decree of 10 August 2018

In-depth link

In-depth link

Italian Celiac Association (AIC)

Ministry of Health. Celiac disease

Ministry of Health. Celiac disease - Annual Report to Parliament. Year 2014

Ministry of Health. National registers of foods for special medical purposes, gluten-free and infant formula

Italian Celiac Association (AIC). The ABC of the celiac diet

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