Shelley Case, RD, presented a very interesting workshop on gluten-related disorders. This refers to a spectrum of all conditions related to gluten, the protein found in all forms of wheat, rye and barley. Gluten-related disorders include celiac disease, wheat allergy, and non-celiac gluten sensitivity.
Celiac disease (CD) affects 1-2% of the general population, with the highest rates in Europe, North and South America, and Australia. It is also common in North Africa, the Middle East and South Asia. It is an inherited autoimmune disorder that can develop at any age. It is a multisystem and multisymptom disease, which affects the GI tract and is now also known to affect nearly all other systems in the body. It is found in 2-15% of 1st degree relatives.
Early onset CD generally occurs within 6-24 months of age. Late onset can occur at any age and can include symptoms such as abdominal pain, bloating, heartburn, nausea/vomiting, gas, diarrhea, and constipation. It can present with weight loss but may also be present in overweight or obese patients.
CD can affect the hematologic system with anemia, iron, folate, and B12 deficiency. It also can affect the cutaneous system with recurrent mouth ulcers, and dermatitis herpetiformis, which can present as a painful itchy rash. Dapsone can be used to control the pain and itch but the only real treatment to stop it is a gluten-free diet. CD can affect the reproductive system with delayed puberty, menstrual irregularity, fertility issues and/or a high degree of miscarriage. The neurological system can be affected with epilepsy, ataxia, and peripheral neuropathy. With respect to the musculoskeletal system, it can affect the dental enamel (common in children who develop symptoms before age 7). Interestingly, 10-15% of short children and teens have evidence of celiac disease. It can also be a cause of osteopenia and osteoporosis. Other miscellaneous findings include elevated transaminases and chronic fatigue.
Complications of undiagnosed CD include early bone disease, infertility in both men and women, associated health problems related to malnutrition and malabsorption, increased risk of developing other autoimmune diseases, and increased risk of GI cancers and lymphoma.
Serological screening tests include testing for IgA TTG (tissue transglutaminase), IgA EMA (endomysial antibody), total IgA levels (selective IgA deficiency is more common in CD than in the general population), and IgG DGP (deamidated gliadin peptide antibody).
The small intestine can also be biopsied, however, false negative results may be obtained if the patient is not on a diet containing gluten. It may be necessary to get your patient back on gluten for approximately a year in order to test positive.
Genetic tests include HLA alleles associated with celiac disease, with DQ2 found in 95% of celiac patients, DQ8 found in remaining patients, and both DQ2/DQ8 found in 30-40% of people with CD.
Non-celiac gluten sensitivity is not autoimmune disorder but people with this condition may present with the same symptoms as someone with CD. Researchers are not sure if it is the gluten that these people are sensitive to or FODMAPs. The term FODMAP is an acronym for "Fermentable, Oligo-, Di-, Mono-saccharides And Polyols." FODMAPs are poorly absorbed in the small intestine.
Ms. Case presented research on fibromyalgia (FM) patients who were placed on a gluten-free diet. Interestingly, the level of chronic widespread pain improved in all FM patients on the gluten-free diet. Another study of patients who had celiac/FM/IBS also improved when placed on a gluten-free diet.
The gluten-free diet seems to be the new fad for celebrities and those wishing to lose weight. The gluten-free diet is a very difficult diet to maintain because there are so many foods that contain gluten, many of which people are not aware of. It is a strict diet that should not be used for weight loss since many of the “gluten-free” foods contain high levels of sugar and lower levels of nutrients than the same foods that contain gluten. So you may need to look for another fad diet if weight loss is your goal!
However, this "gluten buzz" may not be for nothing. We are still under-diagnosing and missing people who have CD and non-celiac gluten sensitivity. The bottom line is, if you see a patient with musculoskeletal symptoms that you cannot figure out, CD should be on your differential.