5.3 Celiac Disease

Understanding Celiac Disease, Diagnosis, Complications, and Approach to Treatment

The human digestive tract from the ingestion to excretion is approximately 30 feet – varying slightly by the size of each individual. The series of digestive organs involved in digestion require substantial length in order to provide sufficient time and surface area for breakdown and absorption of material. Within the small and large intestines, surface area is the most crucial. The small intestine is studded with villi, small hairlike projections off of the intestinal lumen. These villi are composed of a central core with a muscle strand, vein, and centrally located artery. The individual epithelial cells on the surface of the villi that contact the intestinal lumen are covered in more hairlike projections, called microvilli. These projections increase surface area for nutrient absorption in the small intestine. There are no villi or microvilli present in the large intestine. The large intestine absorbs electrolytes, water, and essential vitamins.

Figure 1. Diagram of small intestine villi and microvilli.

The inadequate absorption of nutrients from the gut, malabsorption, leads to increased likelihood for disease and cardiac issues. Malabsorption of micro and macronutrients can be caused by a variety of issues including autoimmune disorders, pancreatic insufficiency, parasitic infections, alcohol abuse, etc.

Autoimmune disorders are a class of medical conditions which cause the immune system to inappropriately attack parts of the body. Celiac disease is an autoimmune disorder which results in an inability to eat gluten (a protein component of wheat) due to an intolerance for the molecule in the digestive tract, where it can cause irreversible damage. Individuals with Celiac disease have an immune response to gluten, which results in damage to the small intestine villi. There is no cure for celiac disease, but it is treated by a gluten-free diet often supervised by a dietician. In cases where patients present with all accompanying symptoms and have undergone genetic testing, celiac disease can be diagnosed without any procedures.

Avoiding gluten can be tricky. The usual suspects that contain gluten are wheat, barley, bulgur, durum, farina, graham flour, malt, rye, semolina, spelt (wheat form), and triticale. However, gluten can also be hidden in other products: soy sauce, modified food starch, preservatives, over the counter medications, vitamins and supplements, lipstick and other makeup products, toothpaste, mouthwash, communion wafers, and even envelope stamp glue. Celiac disease itself is not deadly, however the consequences of symptoms can be. Malnourishment, chronic anemia, and increased risk of certain cancers can ultimately lead to a fatal outcome.

Traditionally, the autoimmune disorder’s complicated symptoms require a complicated and expensive diagnostic effort. Using labs, history, and an endoscopic biopsy, an assessment can be made with great accuracy. Celiac disease once diagnosed is assessed with a Marsh Score, a system created by Dr. Micheal Marsh.

Healthcare providers may refer to celiac disease as ‘mild’ in patients with grade 1 or 2 intestinal damage. This can be misleading because the severity of damage does not determine the presence or overall severity of celiac disease. An individual either has celiac disease or does not, regardless of the extent of intestinal damage.

Celiac disease can easily be confused or conflated with gluten intolerance. This is an inflammatory reaction in the small intestine, as it cannot fully absorb gluten molecules. Individuals with this problem similarly remove gluten from their diet.

Celiac is thought to be an incredibly under diagnosed condition, theoretically only diagnosed in 25% of the population that it should. In populations where the dominant culture consumes more gluten, the symptomatology is made more obvious. Furthermore, populations that are less genetically diverse, have higher incidences of gluten intolerance. Finland and Algeria have two of the highest rates of country wide celiac disease diagnosis.

The diagnosis of this autoimmune disorder is in many ways an ethical concern for doctors and scientific professionals. While an endoscopic biopsy is the most successful diagnostic tool, these tests are difficult to plan, painful, and incredibly expensive. For those without health insurance, testing via this method can essentially be an impossibility. Doctors must use other ways of diagnosis, and an overly cautious attitude in such cases. Black (63%) and Hispanic (49%) Americans are more likely to have no awareness of their own celiac disease or gluten sensitivity, compared with White Americans (47%) – suggesting a large potential health inequity in treatment and diagnosis of the disease.

https://www.beyondceliac.org/celiac-disease-and-health-equity/

https://commons.wikimedia.org/wiki/File:Villi_%26_microvilli_of_small_intestine.svg