What is celiac disease?

Celiac disease is a digestive disease that damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate gluten, a protein in wheat, rye, and barley. Gluten is found mainly in foods but may also be found in everyday products such as medicines, vitamins, and lip balms.

The small intestine is shaded above.
When people with celiac disease eat foods or use products containing gluten, their immune system responds by damaging or destroying villi—the tiny, fingerlike protrusions lining the small intestine. Villi normally allow nutrients from food to be absorbed through the walls of the small intestine into the bloodstream. Without healthy villi, a person becomes malnourished, no matter how much food one eats.

Villi on the lining of the small intestine help absorb nutrients.
Celiac disease is both a disease of malabsorption—meaning nutrients are not absorbed properly—and an abnormal immune reaction to gluten. Celiac disease is also known as celiac sprue, nontropical sprue, and gluten-sensitive enteropathy. Celiac disease is genetic, meaning it runs in families. Sometimes the disease is triggered—or becomes active for the first time—after surgery, pregnancy, childbirth, viral infection, or severe emotional stress.
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What are the symptoms of celiac disease?

Symptoms of celiac disease vary from person to person. Symptoms may occur in the digestive system or in other parts of the body. Digestive symptoms are more common in infants and young children and may include

• abdominal bloating and pain
• chronic diarrhea
• vomiting
• constipation
• pale, foul-smelling, or fatty stool
• weight loss

Irritability is another common symptom in children. Malabsorption of nutrients during the years when nutrition is critical to a child's normal growth and development can result in other problems such as failure to thrive in infants, delayed growth and short stature, delayed puberty, and dental enamel defects of the permanent teeth.
Adults are less likely to have digestive symptoms and may instead have one or more of the following:

• unexplained iron-deficiency anemia
• fatigue
• bone or joint pain
• arthritis
• bone loss or osteoporosis
• depression or anxiety
• tingling numbness in the hands and feet
• seizures
• missed menstrual periods
• infertility or recurrent miscarriage
• canker sores inside the mouth
• an itchy skin rash called dermatitis herpetiformis

People with celiac disease may have no symptoms but can still develop complications of the disease over time. Long-term complications include malnutrition—which can lead to anemia, osteoporosis, and miscarriage, among other problems—liver diseases, and cancers of the intestine.
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Why are celiac disease symptoms so varied?

Researchers are studying the reasons celiac disease affects people differently. The length of time a person was breastfed, the age a person started eating gluten-containing foods, and the amount of gluten-containing foods one eats are three factors thought to play a role in when and how celiac disease appears. Some studies have shown, for example, that the longer a person was breastfed, the later the symptoms of celiac disease appear.
Symptoms also vary depending on a person's age and the degree of damage to the small intestine. Many adults have the disease for a decade or more before they are diagnosed. The longer a person goes undiagnosed and untreated, the greater the chance of developing long-term complications.
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What other health problems do people with celiac disease have?

People with celiac disease tend to have other diseases in which the immune system attacks the body's healthy cells and tissues. The connection between celiac disease and these diseases may be genetic. They include

• type 1 diabetes
• autoimmune thyroid disease
• autoimmune liver disease
• rheumatoid arthritis
• Addison's disease, a condition in which the glands that produce critical hormones are damaged
• Sjögren's syndrome, a condition in which the glands that produce tears and saliva are destroyed

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How common is celiac disease?

Celiac disease affects people in all parts of the world. Originally thought to be a rare childhood syndrome, celiac disease is now known to be a common genetic disorder. More than 2 million people in the United States have the disease, or about 1 in 133 people.1 Among people who have a first-degree relative—a parent, sibling, or child—diagnosed with celiac disease, as many as 1 in 22 people may have the disease.2
Celiac disease is also more common among people with other genetic disorders including Down syndrome and Turner syndrome, a condition that affects girls' development.
1Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States. Archives of Internal Medicine. 2003;163(3):268–292.
2Ibid.
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How is celiac disease diagnosed?

Recognizing celiac disease can be difficult because some of its symptoms are similar to those of other diseases. Celiac disease can be confused with irritable bowel syndrome, iron-deficiency anemia caused by menstrual blood loss, inflammatory bowel disease, diverticulitis, intestinal infections, and chronic fatigue syndrome. As a result, celiac disease has long been underdiagnosed or misdiagnosed. As doctors become more aware of the many varied symptoms of the disease and reliable blood tests become more available, diagnosis rates are increasing.
Blood Tests

People with celiac disease have higher than normal levels of certain autoantibodies—proteins that react against the body's own cells or tissues—in their blood. To diagnose celiac disease, doctors will test blood for high levels of anti-tissue transglutaminase antibodies (tTGA) or anti-endomysium antibodies (EMA). If test results are negative but celiac disease is still suspected, additional blood tests may be needed.
Before being tested, one should continue to eat a diet that includes foods with gluten, such as breads and pastas. If a person stops eating foods with gluten before being tested, the results may be negative for celiac disease even if the disease is present.
Intestinal Biopsy

If blood tests and symptoms suggest celiac disease, a biopsy of the small intestine is performed to confirm the diagnosis. During the biopsy, the doctor removes tiny pieces of tissue from the small intestine to check for damage to the villi. To obtain the tissue sample, the doctor eases a long, thin tube called an endoscope through the patient's mouth and stomach into the small intestine. The doctor then takes the samples using instruments passed through the endoscope.
Dermatitis Herpetiformis

Dermatitis herpetiformis (DH) is an intensely itchy, blistering skin rash that affects 15 to 25 percent of people with celiac disease.3 The rash usually occurs on the elbows, knees, and buttocks. Most people with DH have no digestive symptoms of celiac disease.
DH is diagnosed through blood tests and a skin biopsy. If the antibody tests are positive and the skin biopsy has the typical findings of DH, patients do not need to have an intestinal biopsy. Both the skin disease and the intestinal disease respond to a gluten-free diet and recur if gluten is added back into the diet. The rash symptoms can be controlled with antibiotics such as dapsone. Because dapsone does not treat the intestinal condition, people with DH must maintain a gluten-free diet.
Screening

Screening for celiac disease means testing for the presence of autoantibodies in the blood in people without symptoms. Americans are not routinely screened for celiac disease. However, because celiac disease is hereditary, family members of a person with the disease may wish to be tested. Four to 12 percent of an affected person's first-degree relatives will also have the disease.4
3Rodrigo L. Celiac disease. World Journal of Gastroenterology. 2006;12(41):6585–6593.
4Ibid.
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How is celiac disease treated?

The only treatment for celiac disease is a gluten-free diet. Doctors may ask a newly diagnosed person to work with a dietitian on a gluten-free diet plan. A dietitian is a health care professional who specializes in food and nutrition. Someone with celiac disease can learn from a dietitian how to read ingredient lists and identify foods that contain gluten in order to make informed decisions at the grocery store and when eating out.
For most people, following this diet will stop symptoms, heal existing intestinal damage, and prevent further damage. Improvement begins within days of starting the diet. The small intestine usually heals in 3 to 6 months in children but may take several years in adults. A healed intestine means a person now has villi that can absorb nutrients from food into the bloodstream.
To stay well, people with celiac disease must avoid gluten for the rest of their lives. Eating even a small amount of gluten can damage the small intestine. The damage will occur in anyone with the disease, including people without noticeable symptoms. Depending on a person's age at diagnosis, some problems will not improve, such as short stature and dental enamel defects.
Some people with celiac disease show no improvement on the gluten-free diet. The most common reason for poor response to the diet is that small amounts of gluten are still being consumed. Hidden sources of gluten include additives such as modified food starch, preservatives, and stabilizers made with wheat. And because many corn and rice products are produced in factories that also manufacture wheat products, they can be contaminated with wheat gluten.
Rarely, the intestinal injury will continue despite a strictly gluten-free diet. People with this condition, known as refractory celiac disease, have severely damaged intestines that cannot heal. Because their intestines are not absorbing enough nutrients, they may need to receive nutrients directly into their bloodstream through a vein, or intravenously. Researchers are evaluating drug treatments for refractory celiac disease.
The Gluten-free Diet

A gluten-free diet means not eating foods that contain wheat, rye, and barley. The foods and products made from these grains should also be avoided. In other words, a person with celiac disease should not eat most grain, pasta, cereal, and many processed foods.
Despite these restrictions, people with celiac disease can eat a well-balanced diet with a variety of foods. They can use potato, rice, soy, amaranth, quinoa, buckwheat, or bean flour instead of wheat flour. They can buy gluten-free bread, pasta, and other products from stores that carry organic foods, or order products from special food companies. Gluten-free products are increasingly available from mainstream stores.
“Plain” meat, fish, rice, fruits, and vegetables do not contain gluten, so people with celiac disease can freely eat these foods. In the past, people with celiac disease were advised not to eat oats. New evidence suggests that most people can safely eat small amounts of oats, as long as the oats are not contaminated with wheat gluten during processing. People with celiac disease should work closely with their health care team when deciding whether to include oats in their diet. Examples of other foods that are safe to eat and those that are not are provided in the table.
The gluten-free diet requires a completely new approach to eating. Newly diagnosed people and their families may find support groups helpful as they learn to adjust to a new way of life. People with celiac disease must be cautious about what they buy for lunch at school or work, what they purchase at the grocery store, what they eat at restaurants or parties, and what they grab for a snack. Eating out can be a challenge. When in doubt about a menu item, a person with celiac disease should ask the waiter or chef about ingredients and preparation or if a gluten-free menu is available.
Gluten is also used in some medications. People with celiac disease should ask a pharmacist if prescribed medications contain wheat. Because gluten is sometimes used as an additive in unexpected products—such as lipstick and play dough—reading product labels is important. If the ingredients are not listed on the label, the manufacturer should provide a list upon request. With practice, screening for gluten becomes second nature.
New Food Labeling

The Food Allergen Labeling and Consumer Protection Act (FALCPA), which took effect on January 1, 2006, requires food labels to clearly identify wheat and other common food allergens in the list of ingredients. FALCPA also requires the U.S. Food and Drug Administration to develop and finalize rules for the use of the term “gluten free” on product labels.
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The Gluten-free Diet: Some Examples

In 2006, the American Dietetic Association updated its recommendations for a gluten-free diet. The following chart is based on the 2006 recommendations. This list is not complete, so people with celiac disease should discuss gluten-free food choices with a dietitian or physician who specializes in celiac disease. People with celiac disease should always read food ingredient lists carefully to make sure the food does not contain gluten.
Allowed Foods amaranth
arrowroot
buckwheat
cassava
corn
flax
Indian rice grass
Job's tears legumes
millet
nuts
potatoes
quinoa
rice
sago seeds
sorghum
soy
tapioca
teff
wild rice
yucca Foods To Avoid wheat

• including einkorn, emmer, spelt, kamut
• wheat starch, wheat bran, wheat germ, cracked wheat, hydrolyzed wheat protein

barley
rye
triticale (a cross between wheat and rye) Other Wheat Products bromated flour
durum flour
enriched flour
farina graham flour
phosphated flour
plain flour self-rising flour
semolina
white flour Processed Foods that May Contain Wheat, Barley, or Rye* bouillon cubes
brown rice syrup
candy
chips/potato chips
cold cuts, hot dogs, salami, sausage
communion wafers French fries
gravy
imitation fish
matzo
rice mixes
sauces seasoned tortilla chips
self-basting turkey
soups
soy sauce
vegetables in sauce * Most of these foods can be found gluten-free. When in doubt, check with the food manufacturer.
Source: Thompson T. Celiac Disease Nutrition Guide, 2nd ed. Chicago: American Dietetic Association; 2006. © American Dietetic Association. Adapted with permission. For a complete copy of the Celiac Disease Nutrition Guide, please visit www.eatright.org.
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Points to Remember

• People with celiac disease cannot tolerate gluten, a protein in wheat, rye, and barley.
• Untreated celiac disease damages the small intestine and interferes with nutrient absorption.
• Without treatment, people with celiac disease can develop complications such as osteoporosis, anemia, and cancer.
• A person with celiac disease may or may not have symptoms.
• Diagnosis involves blood tests and, in most cases, a biopsy of the small intestine.
• Since celiac disease is hereditary, family members of a person with celiac disease may wish to be tested.
• Celiac disease is treated by eliminating all gluten from the diet. The gluten-free diet is a lifetime requirement.
• A dietitian can teach a person with celiac disease about food selection, label reading, and other strategies to help manage the disease.

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Hope through Research

The National Institute of Diabetes and Digestive and Kidney Diseases conducts and supports research on celiac disease. Researchers are studying new options for diagnosing celiac disease, including capsule endoscopy. In this technique, patients swallow a capsule containing a tiny video camera that records images of the small intestine.
Several drug treatments for celiac disease are under evaluation. Researchers are also studying a combination of enzymes—proteins that aid chemical reactions in the body—that detoxify gluten before it enters the small intestine.
Scientists are also developing educational materials for standardized medical training to raise awareness among health care providers. The hope is that increased understanding and awareness will lead to earlier diagnosis and treatment of celiac disease.
Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov.

So many people i know suffer from it, esp women.
My brother too. When he was back home the nan did not make him bloat, we assumed the wheat there has less gluten or it is not from crops of recent
/modern hybridised variety.

I am sorry to hear about your Brother. I know how hard it is for

him. I am a Celiac myself. Back home its better to stick to corn. It does cause

a problem when people invite you to dinner though, they think your making

excuses , because you don't like the food. Your sitting there taking oaths

that its not the food.

If untreated can turn to cancer.

Like it did in my friends Husband. Who refused to see a Doctor. She forced

him to get himself checked by a Doctor.

Cancer

Some research has suggested that having coeliac disease can increase your risk of developing certain types of cancer, including:

• bowel cancer
• lymphoma (cancer of the lymphatic system, which is part of the immune system)

The same research found people with coeliac disease have a lower risk of developing lung and breast cancer, although reasons for this are unclear.
It is estimated that people with coeliac disease are twice as likely to develop bowel cancer compared with the general population. However, this is still a very small increase in risk: only 1 in every 200 people with coeliac disease will develop bowel cancer in the first 10 years after diagnosis. As age is an independent risk factor for bowel cancer, your risk of developing bowel cancer increases as you get older, in line with the general population.
The risk of developing cancer is thought highest during the first year after diagnosis, before dropping to normal as your gluten-free diet starts to take effect.
Whether or not you have coeliac disease, it is important to be aware of the symptoms of bowel cancer, which include:

• blood in stools (faeces)
• unexplained weight loss
• change in your normal bowel habit lasting greater than four weeks

Intestinal Cancer and Celiac Disease


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What is intestinal cancer?
Cancer of the small intestine is a rare form of cancer typically caused by four types of tumors or classifications. The most common type of small intestine cancer is adenocarcinoma. Other, less common types are: carcinoid tumors, gastrointestinal stromal tumors and lymphomas.
Celiac Disease and Small Intestinal Cancer:
If a person with celiac had the disease undiagnosed for a long period of time, or fails to maintain a gluten-free lifestyle after diagnosis, the chance of developing small intestinal cancer increases. Those with celiac disease are especially more likely to develop lymphomas in the small intestine because of their compromised immune system. In the past the increased risk of celiacs developing lymphomas was quite high, 40-100% more likely. However, more recent studies have shown that the risk of lymphoma is slightly higher than the normal population—much less than previously believed—and that this risk reaches unity with the normal population after a gluten-free diet has been maintained for several years.
Types of Intestinal Cancers:

• Adenocarcinoma: A type of cancer that begins in the lining of the small intestine, usually the duodenum. Adenocarcinomas make up 40-50% of all small intestinal cancers.
  
  Who Gets Adenocarcinoma?
  This type of intestinal cancer occurs most often in men later in life, the average age being 60 years. People with Crohns Disease and certain other inherited conditions—such as familial adenomatous polyposis and Peuts-Jegherssyndrome are at a higher risk of developing adenocarinomas.
• Carcinoid Tumors: Occurs when neuroendocrine cells grow abnormally, carcinoid tumors may also be refered to as neuroendocrine tumors or less aggressive neuroendocrine cancer. Carcinoid tumors often cause symptoms throughout the entire body, rather than just in the affected organ.
  
  Who Gets Carcinoid Tumors?
  People with a family history of multiple endocrine neoplasia—a rare inherited disease that causes increased risk of getting tumors in certain glands, or those with a family history of neurofibromatosis. Carcinoid tumors are more common in women and among African Americans. People with certain diseases that damage the stomach and reduce the amount of stomach acid have an increased risk of developing carinoid tumors.
• Gastrointestinal Stromal Tumors: These are fairly rare tumors that are now believed to start in the interstitial cells of Cajal (ICCs) in the walls of the GI tract. Some stromal tumors are benign.
  
  Who Gets Stromal Tumors?
  There are very few known risk factors that cause stromal tumors, it is believed that a family history of neurofibromatosis or familial gastrointestinal stromal tumor syndrome will increase a person's risk of getting stromal tumors.
• Lymphomas: Cancer of the lymphatic system that begins in the lymphoid tissue.
  
  Who Gets GI Lymphomas?
  Most patients have no known risk factors, old age seems to be the greatest factor in developing lymphomas. Some genetic risks factors that cause abnormal function of the immune system can also lead to lymphomas, as well as a diet high in animal fat and low in fruits and vegetables. Exposure to radiation and certain chemicals can increase the risk of lymphomas. Immune deficiencies—from organ transplants, etc, autoimmune diseases, and some infections can also increase the likelihood of a lymphoma developing.

What are the Symptoms of Intestinal Cancer?
Symptoms tend to be vague and unspecific. Complaints are often for pain throughout the body, not just focused in the digestive tract area. Abdominal pain and unexplained weight-loss are the two most common symptoms of intestinal cancer. Other symptoms include, but are not limited to, pain or cramping in the middle of the abdomen, a lump in the abdomen, blood in the stool, nausea, bloating, iron deficient anemia and jaundice.
Screening and Diagnosis of Intestinal Cancer
If your doctor suspects intestinal cancer they might order a barium contrast study, an upper GI tract endoscopy, an ultrasound or a colonoscopy depending on what type of cancer is suspected and the likely location. If tumors are found a biopsy will be performed to confirm that the cells are cancerous.
Treatment of Small Intestinal Cancer
The most common method of treatment of small intestinal cancer is surgery. The doctor will remove all of the visible tumor and some of the surrounding healthy area to ensure that all cancer has been removed. With lymphomas, the most common treatment is radiation therapy.
Celiac Disease and Other Malignancies
Although cancers of the small intestine might seem to be the only related malignancy with celiac, other studies have shown relations with other types of cancer. There is some evidence that patients with celiac have an increased risk of esophageal and pharyngeal carcinomas, a Swedish study found celiac 2.3 times more likely to develop these carcinomas. The same study also found an increased risk for colorectal cancer (SIR=1.5), however an English study found NO patients with celiac disease and colorectal cancer. Celiacs also seem to have an increased risk of developing primary liver cancer. Breast cancer, on the other hand, is seen at a much lower frequency in celiacs than among the general population. This is possibly related to a lower frequency of smoking or lower body weight in celiacs.
The development of malignancies is rare, and although celiac disease does appear to coincide with increased frequencies of certain cancers it is by no means a common occurrence. If you suspect that you might have cancer, or are worried about developing cancer in the future, please discuss your concerns with your physician.

Coeliac disease (coeliac sprue or gluten allergy)

Reviewed by Health Advisory Council , Coeliac UK

What is coeliac disease?

Term watch

Coeliac disease is also known as gluten enteropathy or coeliac sprue.


Coeliac disease is a lifelong autoimmune condition, which is a multi-system disorder diagnosed by endoscopy with biopsy, of the small intestine (bowel).
Gluten is predominantly a mixture of two proteins, gliadin and glutenin. It is found in wheat, barley and rye. When combined with water gluten becomes sticky and forms the familiar texture of dough.
In coeliac disease, gluten causes the immune system to produce antibodies that attack the delicate lining of the bowel, which is responsible for absorbing nutrients and vitamins from food.
Coeliac disease can be diagnosed at any age and can be diagnosed in babies after weaning, when cereals containing gluten are first introduced into the diet. However, the most common age of diagnosis is currently between 40 and 60 years old.
The symptoms can be subtle, and you may feel unwell for some time for no reason before the diagnosis is made.
If left untreated, coeliac disease can lead to anaemia, low bone density, osteoporosis and, rarely, some forms of gut cancer.
Avoiding all food that contains gluten generally results in the improvement, or even disappearance, of damage to the bowel lining. However, the damage will start again if gluten is re-introduced into the diet.
How does gluten damage the bowel?


Healthy villi of the small intestine (as seen under the microscope).
Damaged villi of the small intestine.
Villi completely destroyed by the immune system. All pictures courtesy of Prof PJ Ciclitira.
The small bowel contains villi, which are tiny finger-like projections that are only visible under a microscope.
They provide a large surface area over which we absorb nutrients such as folic acid, iron and calcium.
If you have coeliac disease, a reaction occurs when gluten comes into contact with the lining of the small bowel.
The villi are attacked by the immune system and become inflamed and flattened, as seen in the pictures above.
This results in nutrients from food going down the gut without being absorbed (malabsorption), leading to diarrhoea, vitamin and mineral deficiencies, anaemia and thin bones (osteoporosis).
Who is at risk?

It used to be thought that coeliac disease affected about 1 in 1500 people. More accurate diagnosis through blood tests has shown that the condition affects 1 per cent of people across Europe. Coeliac disease affects all ethnic groups and is common not just in Europe, but also in South Asia, the Middle East, North West and East Africa and South America.
Coeliac disease is more common in women than men.
Coeliac disease is associated with other conditions. People with Type 1 diabetes, and thyroid problems have an increased chance of developing coeliac disease.
The risk of coeliac disease is increased by a family history of the condition. Coeliac disease occurs in people who are genetically prone to it.
If you have a parent, sibling or child with coeliac disease, you have a 10 per cent chance of also developing it. In identical twins, if one twin has coeliac disease, the chance of the other twin developing coeliac disease is more than 70 per cent.
What are the symptoms?

Term watch

Villi are finger like projections in the gut. They help the body to absorb nutrients from the food we eat.


Coeliac disease has many and varied symptoms, and symptoms in adults may be different to those in children. Symptoms do not appear until gluten-containing foods (bread, cereal) are introduced into the diet.
Childhood symptoms

In childhood: poor appetite, irritability and a failure to thrive are usually the first symptoms.

• Poor appetite, irritability and a failure to gain weight are usually the first symptoms.
• Pale, bulky stools that smell nasty.
• Vomiting and diarrhoea, which can lead to a wrong diagnosis of gastroenteritis.
• Swollen stomach.
• Arm and leg muscles may become wasted and thin.

Adult symptoms

In adults symptoms may include:

• weight loss with pale, offensive diarrhoea
• constipation
• abdominal bloating with wind.

However, adults with coeliac disease may not have any of these bowel symptoms. They approach their doctor because of:

• extreme tiredness
• anaemia
• depression
• bone pain and sometimes even fractures – which are due to thinning of the bones
• ulcers in the mouth
• a blistering, itchy skin rash mostly on the elbows and knees, called dermatitis herpetiformis
• recurrent miscarriages.

More recent research suggests that loss of balance (ataxia) and tingling in the hands and feet (neuropathy) are neurological symptoms found in people with coeliac disease.
The gut symptoms seen in coeliac disease may not always be present in people with the neurological symptoms.

How is coeliac disease diagnosed?

Your GP will ask about your symptoms. Don't feel embarrassed about questions on the frequency and colour of your bowel motions.
Your doctor may also want to know whether you have lost weight or whether you have symptoms of anaemia (tiredness, exhaustion, pallor). The doctor may:

• examine your abdomen
• look for a blistering rash on your skin
• check for mouth ulcers.

Blood tests are then usually requested.

• Your doctor will check for anaemia, testing the levels of iron, folic acid and calcium in your blood.
• Another blood test detects antibodies that are often found in coeliac disease. Several antibodies are linked to the condition, but the most specific is anti-endomysial antibody. If this is present in the blood, you are very likely to have coeliac disease.

An endoscopy with biopsy is needed to diagnose coeliac disease. Your doctor should arrange this test at the endoscopy unit at your local hospital.
Children can have endoscopy under general anaesthetic (sedation) and adults may have sedation or a local anaesthetic that numbs the throat with a spray.
It's important that you continue to have a normal diet that contains gluten before having the blood tests and endoscopy for coeliac disease.
The NICE guideline recommends that if the diet has been changed, foods that contain gluten should be eaten in at least one meal everyday for at least six weeks before testing.
Endoscopy and biopsy

• A thin flexible tube with a tiny camera and clipper at its end is put into your mouth.
• The camera is guided down the oesophagus (gullet) into the stomach and then the small bowel.
• The clipper can be used to remove a small piece of the bowel lining during the procedure. This is called a biopsy. You will not feel any discomfort.
• The whole procedure takes about 10 minutes.
• The biopsy specimen will be sent to the laboratory to examine the size and shape of the villi. This will confirm diagnosis.
• It is usual to repeat this test after several months on a gluten-free diet, to check that the lining has recovered.

What else could it be?

Diarrhoea and weight loss can be due to several other causes.

• A bowel infection caused by parasites called Giardia lamblia and Strongyloides. If your symptoms start after a tropical holiday, one of these infections may be to blame.
• Overgrowth of bacteria in the small intestine.
• Lactose (milk) intolerance.
• Whipple's disease (a rare disease in men that prevents nutrients and fat being absorbed).
• Intestinal lymphoma (a type of cancer).

What treatment is available?

It's not possible to prevent coeliac disease, but a gluten-free diet can reverse damage to the small intestine. This requires considerable support and information..
After diagnosis your GP should refer you for a consultation with a dietitian, who can give you diet sheets and advice.
It's important that you receive regular follow up from your healthcare team. The general recommendations are to have an annual review appointment.
Another important aspect of treatment is recommending supplements for vitamins and minerals.
If nutrient levels are low, you may need iron tablets, folic acid supplements and calcium. All women should take a folic acid supplement of 400 micrograms a day for three months before conception and for the first three months of pregnancy. This is to protect against neural tube defects such as spina bifida.
If your folic acid levels are low before conception you may need to take a higher dose of five milligrams a day.
It's important to discuss supplements with your GP or local dietitian as they can help to access your individual needs.
Coeliac disease that does not respond to a gluten-free diet may need additional treatment.
In the vast majority of cases, failure of the gut to heal is due to continued gluten in the diet.
If you have been told that your gut has not healed it is important that you see a registered dietitian who can discuss your diet in more detail. Refractory coeliac disease is a term used to describe a condition that does not respond despite following a strict gluten-free diet.
Treatment may include the use of steroids and drugs that 'damp down' the immune system. This is rare.
The gluten-free diet can be nutritionally adequate and balanced. However, the gluten-free diet can be low in fibre and wholegrains, which can cause constipation in some people.
To counteract this, eat plenty of fruit and vegetables.
Tips to increase your fibre intake when following a strict gluten-free diet can be found on the Coeliac UK website. If constipation persists, speak to your local pharmacist, dietitian or GP for further advice.
What is a gluten-free diet?

Things to avoid

The gluten-free diet involves avoiding gluten, the protein found in wheat, rye and barley. Some people are also sensitive to oats.
Gluten is found in the following foods.

• Bread, pasta and breakfast cereals.
• Pizza bases.
• Biscuits, cakes and pastries.
• Some soy sauces, mustards and mayonnaises.
• Some tinned soups, sauces, ready meals and some processed foods.
• Some crisps and similar snacks.
• Chips should be avoided if cooked in the same oil as battered fish.
• Beer, lager, stouts and ales are made from grain containing gluten, but other alcoholic drinks such as wine, cider, sherry, spirits and liqueurs can be included in the gluten-free diet.

Most people with coeliac disease can include gluten-free oats in the diet.
Oats are often processed and milled in the same place as wheat. It is therefore important that those including oats in the diet choose gluten-free oats.
Some people can be sensitive to gluten-free oats. This is because oats contain a gluten-like protein called avenin.
If you are thinking about including pure, uncontaminated oats in your gluten-free diet, you should discuss this with your healthcare team (GP, registered dietitian, gastroenterologist) for specific guidance and on-going monitoring.
Current recommendations are that all oats and oat products should be avoided for the first 6 months after diagnosis of coeliac disease to enable you to understand how it feels to be without symptoms.
Prescription medications and medications with a product licence number on the packet are gluten-free.
If a medicine contains wheat starch, this will be indicated on the label and in the patient information leaflet. If concerned you should check with your doctor or pharmacist before taking them.

Foods you can eat

Many foods do not contain gluten, including:

• all fruit, salads, vegetables
• potatoes
• rice and maize
• nuts
• pulses and lentils
• red meat, chicken, fish, eggs and dairy products
• processed foods such as ready meals and soups which are made without gluten

Coeliac UK produce a food and drink directory, listing foods that can be included in the gluten-free diet.
Gluten-free substitutes are available from most supermarkets and pharmacies. You can also get staples such as gluten-free flour, breads and pasta on prescription from your doctor.
There are excellent books available on gluten-intolerance, including general guides and recipe books.

What complications can coeliac disease cause?

Complications of coeliac disease are rare. They include the following.
Term watch

Autoimmune disease: a disease where the immune system attacks the bodies own cells.
Coeliac disease is an autoimmune disease.

• Infertility in women. Recurrent miscarriage is sometimes associated with coeliac disease.
• Severe anaemia in pregnancy because the bowel cannot absorb enough iron and vitamins to keep up with the demands of mother and baby.
• Intrauterine growth retardation. Babies who are small for their age in the womb are more frequently born to mothers with coeliac disease.
• Autoimmune diseases (thyroid disease, Type 1 diabetes and some types of liver disease such as primary biliary cirrhosis).
• Thinning of the bones (osteoporosis).
• A slightly increased risk of developing bowel cancer, intestinal lymphoma and cancer of the oesophagus.

A gluten-free diet reduces all these complications, as well as treating associated symptoms and conditions such as diarrhoea, mouth ulcers and dermatitis herpetiformis.
Studies have shown that sticking to a gluten-free diet for five years or more reduces the risk of all cancers associated with coeliac disease to that of the general population.
Is there a cure for coeliac disease?

A gluten-free diet should enable the lining of the bowel to return to normal in most people. But damage will return as soon as you start eating gluten again.
This means the disease can be 'cured', but only by avoiding foods that contain gluten. If you do this, you can enjoy a good quality of life without symptoms or long-term complications.




Coeliac Disease is just a little bit different.