Coeliac disease

Coeliac disease (Commonwealth English) or celiac disease (American English) is a chronic autoimmune disease, mainly affecting the small intestine. It is caused by an abnormal immune system response to gluten, a protein found in wheat and other grains such as barley and rye. Coeliac disease causes a wide range of symptoms and complications that can affect multiple organs outside the gastrointestinal tract.

The classic form of the disease can affect any age group, but is usually diagnosed in early childhood and causes symptoms of malabsorption such as weight loss, diarrhoea, and stunted growth. Non-classic coeliac disease is more commonly seen in adults, characterised by vague abdominal symptoms and complications in organs outside the gastrointestinal tract, such as bone disease, anaemia, and other consequences of nutritional deficiencies. In people with a genetic predisposition to the condition, eating gluten causes inflammation in the small intestine, damaging its lining and leading to malabsorption. The development of coeliac disease is believed to be influenced by other environmental factors, such as infections.

Diagnosis is based on symptoms, blood tests, and biopsies of the small intestine. For people who have already cut gluten from their diet, gluten may need to be reintroduced before testing to ensure an accurate diagnosis. A lack of awareness and the diverse symptoms, which overlap with other disorders, often complicate the diagnosis by leading to a delay in diagnosis. Current research indicates that there is not enough evidence to advocate for mass screening for coeliac disease in those without symptoms.

The only treatment for coeliac disease is a lifelong gluten-free diet (GFD). A GFD involves removing all food and drink containing wheat, rye, barley, and gluten derivatives. Symptoms can improve within days of adopting a GFD, and the diet can improve quality of life, prevent further complications, and normalise some effects of the disease such as stunted growth.

Approximately 1 in 200 to 1 in 50 people have coeliac disease. Diagnoses of coeliac disease have increased recently due to increased awareness and availability of blood testing. The disease is still thought to be underdiagnosed, with a significant number of people with the condition remaining undiagnosed and untreated. The disease usually develops before age 10; it is slightly more common in women than in men.

Terminology and classification

"Coeliac disease" is the preferred spelling in Commonwealth English, whereas "celiac disease" is typically used in North American English. The terms sprue, coeliac sprue, gluten-sensitive enteropathy, non-tropical sprue and idiopathic steatorrhoea have been used as synonyms for coeliac disease in the past. Both gluten intolerance and gluten sensitivity have been used as synonyms of coeliac disease or to describe other symptoms triggered by gluten. The terms are nonspecific and lack a consistent definition. Gluten-related disorders are conditions related to gluten such as coeliac disease, gluten ataxia, wheat allergy, dermatitis herpetiformis, and non-coeliac gluten sensitivity.

Many individuals with coeliac disease are asymptomatic, The presentation of coeliac disease can be classified as classic, non-classic, and subclinical. Non-classic coeliac disease is seen more often in adults, and symptoms primarily manifest outside the intestine (extraintestinal).

Gastrointestinal

Diarrhoea that is characteristic of coeliac disease is chronic, sometimes pale, of large volume, and abnormally foul in odour. Other symptoms of coeliac disease include abdominal pain, cramping, bloating with abdominal distension, and mouth ulcers. As the bowels become more damaged, lactose intolerance can develop.

Extraintestinal manifestations

thumb|upright=1.2|Dysfunctional [[Bone remodeling|bone metabolism in coeliac disease|alt=A visual explaining the mechanisms for bone manifestations of coeliac disease]]

Coeliac disease is a systemic disorder, meaning it affects the entire body. Although many common symptoms of the disease are related to the gastrointestinal tract, those with coeliac disease may also experience symptoms and complications in other organs, known as extraintestinal manifestations. These manifestations may be related to malabsorption or systemic inflammation. Common extraintestinal manifestations of coeliac disease include headaches, fatigue, brain fog, muscle pain, and joint pain.

Nutritional status in coeliac disease may be compromised due to lower intake, maldigestion, and malabsorption, leading to nutritional deficiencies. Common deficiencies in coeliac disease include iron, folate, zinc, vitamin D, and vitamin B<sub>12</sub>. found in wheat and to similar proteins found in the crops of the tribe Triticeae (which includes other common grains such as barley and rye) and to the tribe Aveneae (oats). Wheat subspecies (such as spelt, durum, and khorasan wheat) and wheat hybrids (such as triticale) also cause symptoms of coeliac disease.

A small number of people with coeliac disease react to oats. Sensitivity to oats in coeliac disease may be due to cross-contamination of oats and other foods with gluten, differences between gluten content, immunoreactivity, and genetic variability seen between oat cultivars or dietary intolerance to oats. Most people with coeliac disease do not have adverse reactions to uncontaminated or 'pure' oats, however clinical guidelines differ on whether those with coeliac disease should consume oats.

Other cereals such as maize, millet, sorghum, teff, rice, and wild rice are safe for people with coeliac disease to consume, as well as non-cereals such as amaranth, quinoa, and buckwheat. Noncereal carbohydrate-rich foods such as potatoes and bananas do not contain gluten and do not trigger symptoms.

Risk modifiers

Environmental factors such as infections, geographic latitude, birth weight, antibiotic use, intestinal microbiota, socioeconomic status, hygiene, breastfeeding, and the timing of introduction of gluten into an infant's diet are theorised to contribute to the development of coeliac disease in genetically predisposed individuals.

Mechanism

Coeliac disease appears to be multifactorial, both in that more than one genetic factor can cause the disease, and in that more than one factor is necessary for the disease to manifest in a person.

Almost all people with coeliac disease have either the HLA-DQ2 variant (allele) or, less commonly, the HLA-DQ8 allele. However, about 40% of people without coeliac disease have also inherited either of these alleles. This suggests that additional factors are needed for coeliac disease to develop; that is, the predisposing HLA risk allele is necessary but not sufficient to develop coeliac disease. Furthermore, a small percentage of those who do develop coeliac disease do not have typical HLA-DQ2 or HLA-DQ8 alleles. (also called the human leukocyte antigen) system and is used by the immune system to distinguish between the body's own cells and others. The two subunits of the HLA-DQ protein are encoded by the HLA-DQA1 and HLA-DQB1 genes, located on the short arm of chromosome 6.

There are seven HLA-DQ variants (DQ2 and DQ4–DQ9). Over 95% of people with coeliac disease have the isoform of DQ2 or DQ8, which is inherited in families. The reason these genes increase the risk of coeliac disease is that the receptors formed by these genes bind to gliadin peptides more tightly than other forms of the antigen-presenting receptor. Therefore, these forms of the receptor are more likely to activate T lymphocytes and initiate the autoimmune process. In most individuals, this DQ2.5 isoform is encoded by one of two chromosomes 6 inherited from parents (DQ2.5cis). Most coeliacs inherit only one copy of this DQ2.5 haplotype, while some inherit it from both parents; the latter are especially at risk of coeliac disease as well as being more susceptible to severe complications. The frequency of coeliac disease haplotypes can vary by geography. The prevalence of the HLA-DQ2 genotype and gluten consumption has increased over time. Since untreated coeliac disease can cause serious health problems and affect fertility, it would be expected that HLA-DQ2 and HLA-DQ8 would become less common. The opposite is true—they are most common in areas where gluten-rich foods have been eaten for thousands of years. The HLA-DQ2 gene may have been genetically favoured in the past because it helps protect against tooth decay.

Prolamins

thumb|upright=1.4|Small-bowel mucosal TG2 (red)-specific IgA deposits (green). A) Positive staining (arrow) in the mucosal villous of a short-term treated coeliac disease patient (gluten-free diet for three years). B) Negative IgA deposits (arrow) in the small-bowel mucosa of a long-term treated coeliac disease patient (gluten-free diet for eight years). Co-localisation of IgA deposits with TG2 is shown in yellow.|alt=Biopsy of the intestines of someone with coeliac disease showing antibody deposits

Most of the proteins in food responsible for the immune reaction in coeliac disease are prolamins. These are storage proteins rich in proline (prol-) and glutamine (-amin) that dissolve in alcohols and are resistant to proteases and peptidases of the gut. Prolamins are found in cereal grains with different grains having different but related prolamins: wheat (gliadin), barley (hordein), rye (secalin) and oats (avenin).

thumb|upright=1.4|Schematic representation of intestinal mucosal events involved in coeliac disease pathogenesis|alt=Visual graphic describing the mechanisms of coeliac disease within the intestines

Deamidation is the reaction by which a glutamate residue is formed by cleavage of the epsilon-amino group of a glutamine side chain. Transamidation is the cross-linking of a glutamine residue from the gliadin peptide to a lysine residue of tTg in a reaction that is catalysed by the transglutaminase.

Stored biopsies from people with suspected coeliac disease have revealed that autoantibody deposits in the subclinical coeliacs are detected before clinical disease. Delays in diagnosis can reduce quality of life, use more medical resources and increase risk of complications associated with the disease.

Coeliac disease is diagnosed based on symptoms, blood tests, and biopsies of the small intestine. Within months of eliminating gluten from one's diet, antibodies associated with coeliac disease decrease, meaning that gluten has to be reintroduced several weeks before diagnostic testing.

Blood tests

thumb|[[Immunofluorescence staining pattern of endomysial antibodies on a monkey oesophagus tissue sample|alt=Immunofluorescence stain of antibodies]]

Current medical guidelines recommend testing tissue transglutaminase 2 immunoglobulin A (TTG IgA) in those with suspected coeliac disease. Because IgA deficiency is more common in those with coeliac disease, guidelines recommend testing for IgA deficiency as a part of the diagnostic workup for coeliac disease. If an individual with IgA deficiency is getting tested for coeliac disease, immunoglobulin G (IgG) based tests such as deamidated gliadin peptide IgG (DGP IgG) or endomysial antibody (EMA) can be used instead of IgA-based tests. DGP IgG is used to evaluate coeliac disease in those with IgA deficiency. Coeliac disease is more common in those with IgA deficiency, so medical guidelines recommend that people being tested for coeliac disease are also tested for IgA deficiency. Because IgA-based tests are unreliable in those with IgA deficiency, IgG-based tests are used instead. These include EMA IgG, DGP IgG, and TTG IgA, which are less accurate than IgA testing. Multiparametric serological assays allowing simultaneous detection of TG2 IgA and total IgA have been proposed to improve screening efficiency for coeliac disease. A study evaluating the Polycheck ® Celiac IgA + total IgA test reported high sensitivity and specificity for TG2 IgA and total IgA measurements in coeliac disease diagnostics.

A 2020 guideline by the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) suggests biopsy can be avoided in children who have symptoms of coeliac disease, TTG IgA levels ten times higher than normal, and a positive EMA antibody. There is insufficient evidence to suggest that a nonbiopsy approach can be used in adults. Endoscopic features of coeliac disease include scalloping of the small bowel folds (pictured), fissures, a mosaic pattern to the mucosa, prominence of the submucosa blood vessels, and a nodular pattern to the mucosa. The Marsh classification is based on three histological features: intraepithelial lymphocytes count above 25/100 enterocytes (intraepithelial lymphocytosis), elongated crypts of Lieberkuhn (crypt hyperplasia), and shortening or absence of villi (villous atrophy). As these features can be seen in other disorders, they are not diagnostic for coeliac disease without serological or clinical indications. Due to the lack of evidence that screening for coeliac disease in those without symptoms, clinical guidelines advise testing people based on symptoms and selective screening for certain populations at a higher risk of developing coeliac disease.

Non-responsive coeliac disease

thumb|upright=1.4|Approach to investigating non-responsive coeliac disease|alt=Visual graphic showing the steps taken to diagnose non-responsive coeliac disease

Around 20–40% of those with coeliac disease experience non-responsive coeliac disease (NRCD), which is the continuation of symptoms despite elimination of gluten from their diets for at least 6 to 12 months. Rates vary in different regions of the world; coeliac disease is less common in places where gluten-containing crops are rarely eaten, and in parts of east Asia and sub-Saharan Africa where populations rarely carry the HLA-DQ genes that predispose to the disease.

Diagnoses of coeliac disease have increased dramatically in recent decades due to increased awareness of the disease and the availability of blood testing. However, the disease is still thought to be underdiagnosed, with an estimated 70% of people with coeliac disease undiagnosed and untreated. Undiagnosed cases are more common in poorer areas and in countries that do not regularly test at-risk people. Roughly 20 percent of individuals with coeliac disease are diagnosed after 60 years of age. Coeliac disease is slightly more common in women than in men, though some of that may be due to differences in diagnostic practice, as men with gastrointestinal symptoms are less likely to receive a biopsy than women.

Humans first cultivated grains in the Neolithic period (beginning about 9500 BCE) in the Fertile Crescent in Western Asia; coeliac disease likely did not occur before this time. Aretaeus of Cappadocia, living in the 2nd century in the same area, recorded a malabsorptive syndrome with chronic diarrhoea, causing a debilitation of the whole body.

Post-1800s

Aretaeus of Cappadocia's "Cœliac Affection" gained the attention of Western medicine when Francis Adams presented a translation of Aretaeus's work at the Sydenham Society in 1856. The patient described in Aretaeus's work had stomach pain and was atrophied, pale, feeble, and incapable of work. The diarrhoea manifested as loose stools that were white, malodorous, and flatulent, and the disease was intractable and liable to periodic return. Aretaeus believed a lack of heat in the stomach, necessary for digestion, and a reduced ability to distribute the digestive products throughout the body, caused this incomplete digestion, resulting in diarrhoea. He regarded this as an affliction of the old and more commonly affecting women, explicitly excluding children. The cause, according to Aretaeus, was sometimes either another chronic disease or even consuming "a copious draught of cold water."

Christian Archibald Herter, an American physician, wrote a book in 1908 on children with coeliac disease, which he called "intestinal infantilism". He noted their growth was retarded and that fat was better tolerated than carbohydrate. The eponym Gee-Herter disease was sometimes used to acknowledge both contributions. Sidney V. Haas, an American paediatrician, reported positive effects of a diet of bananas in 1924. This diet remained in vogue until the actual cause of coeliac disease was determined. Clinical improvement of his patients during the Dutch famine of 1944–1945 (during which flour was scarce) likely contributed to his discovery. Dicke noticed that the shortage of bread led to a significant drop in the death rate among children affected by coeliac disease from greater than 35% to essentially zero. He also reported that once wheat was again available after the conflict, the mortality rate soared to previous levels. The link with the gluten component of wheat was made in 1952 by a team from Birmingham, England. Villous atrophy was described by British physician John W. Paulley in 1954 on samples taken at surgery. This encouraged biopsy samples taken by endoscopy. In 1966, dermatitis herpetiformis was linked to gluten sensitivity.

Society and culture

May has been designated as "Coeliac Awareness Month" by several coeliac organisations.

Dietary challenges

Adhering to the GFD can negatively impact those with coeliac disease, requiring major changes for an individual and their family. The restrictive nature of the GFD can lead to no longer enjoying food and pressure to be constantly vigilant about diet. The social life of those with coeliac disease is also negatively affected by the GFD. Receiving a diagnosis of coeliac disease and the dietary changes required to manage the disorder can affect a person's relationship with food and lead to disordered eating as well as anxiety and depression. Small communion wafers typically contain 2–5 mg of gliadin if they are not a gluten-free variety, and many people with coeliac disease report altering their religious practices because of coeliac symptoms caused by these wafers.

Some Christian churches such as the United Methodist, Christian Reformed, Episcopal, Anglican and Lutheran churches offer their communicants gluten-free alternatives, usually in the form of a rice-based cracker or gluten-free bread. Catholics may receive from the chalice alone, or ask for gluten-reduced hosts; gluten-free ones however are not considered still to be wheat bread, and hence are invalid matter.

Roman Catholic doctrine states that for a valid Eucharist, the bread to be used at Mass must be made from wheat. Low-gluten hosts meet all of the Catholic Church's requirements, but they are not entirely gluten-free. As of 2017, the Vatican still disapproves of the use of gluten-free bread for Holy Communion.

Passover

The Jewish festival of Pesach (Passover) may present problems with its obligation to eat matzah, which is unleavened bread made in a strictly controlled manner from wheat, barley, spelt, oats, or rye. In addition, many other grains that are normally used as substitutes for people with gluten sensitivity, including rice, are avoided altogether on Passover by Ashkenazi Jews. Many kosher-for-Passover products avoid grains altogether and are therefore gluten-free. Potato starch is the primary starch used to replace grains.

Research directions

Research into diagnosis has aimed to develop new blood tests, including tests that could be used for those who are not currently eating gluten. These tests measure certain immune cells that react to gluten, such as CD4+ T cells and HLA-DQ-gluten tetramers.

New technologies have been developed to help people follow a GFD in recent years. Food sensors, such as the Nima sensor, could help people measure the amount of gluten in food to prevent accidental gluten consumption. Testing kits that measure gluten levels in urine and waste may help measure adherence the GFD.

Many strategies have been proposed to develop new treatments for coeliac disease. Altering wheat to be safer for those with coeliac disease has been explored using methods such as genetic wheat manipulation and using a chemical process (transamidation) that changes gluten proteins so they no longer trigger an immune reaction. Medications and techniques such as chitosan and AGY gluten sequestering aim to prevent gluten from interacting with the immune system.