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Course: Celiac Disease Return to Course Outline

Celiac Disease

Barbara is a 45-year-old woman with a history of gastrointestinal (GI) complaints for more than 10 years. At the time the gastrointestinal symptoms began, she consulted a physician. All studies came up negative and she was told she had an idiopathic GI disorder. After about 5 years, she consulted a gastroenterologist, who diagnosed her with irritable bowel syndrome and prescribed medication. This had little effect on her symptoms.

At the time of admission to the hospital, she has lost considerable weight, going from her usual 165 lbs. to 125 lbs. She feels depressed, has difficulty sleeping, expresses fatigue, and has frequent diarrhea with fatty stools with flatulence.

While she is hospitalized, one of the consulting physicians suggests testing for celiac disease (CD) as part of the overall workup. After positive blood work and biopsy of the small intestine, she is diagnosed with CD. The hospital dietitian consults with Barbara and begins the educational process along with a referral to a local peer support group.

Within a few short days of adopting a gluten-free diet, Barbara is free of diarrhea for the first time in many years. On outpatient follow-up visits, her weight gradually increases and her symptoms diminish. Six months after her diagnosis, she is at a healthy weight and symptom-free. She continues regular follow-ups to monitor her progress and check for the resolution of damage to her small intestine as well as any nutritional deficiencies.

Autoimmune Etiology

CD is a genetically inherited autoimmune disease that results in intolerance to the proteins found in wheat, barley and rye. These proteins are collectively referred to as "gluten." Gluten is the elastic protein that binds together foodstuffs made with these grains. There are two groups of proteins in gluten: prolamines and glutenins. The suspect protein is a prolamine called gliadin. Oats commonly are contaminated with wheat during the growing or storing processes. Therefore, it is recommended that individuals with CD avoid oats as well.

The ancient Roman physician Galen first described CD. He used the Greek word "koiliakos" meaning "suffering of the bowels." This word eventually was translated into celiac. Despite the antiquity of knowledge about the disease, there was little progress in a clinical diagnosis and treatment.

A significant discovery came about due to rationing during World War II in Europe. The dramatic shortages of grains, especially wheat, rye, barley and oats, resulted in their exclusion from the diets of children and adults. Physicians noted dramatic change in some children, who previously had failed to thrive, once they were placed on a strict diet of alternative grains. Appetites rebounded and the children gained weight.

Further research demonstrated a gluten-free diet was required for healing and good health. Development of the flexible endoscope enabled doctors to biopsy the small intestine and observe the flattening of the villi that is characteristic of CD.


Villi are finger-like projections in the intestine where nutrients are absorbed. When individuals with CD ingest gluten, an autoimmune reaction results, causing damage to the villi in the small intestine, and/or a burning, blistering, itchy rash. Approximately 5 percent of people with CD have a skin rash known as dermatitis herpetiformis (DH). Most of the symptoms related to CD are due to the damaged villi and the resulting malabsorption of nutrients.

Reactions to ingesting gluten take a variety of forms and may occur immediately or be delayed. It also is possible for the effect to be subclinical, causing intestinal damage without outward symptoms. People with CD often are challenged with the medical requirement to avoid all gluten. Recent research has shown that 1/8 of a teaspoon of gluten has a negative impact on the intestinal villi. (This amount is equivalent to 1/1,000 of a slice of bread.) Therefore, the only option for a person with CD is a strict gluten-free diet for life.

There is a strong genetic predisposition to CD, though an understanding of the exact mechanism is the subject of ongoing research. The disease is seen more commonly in women than men, with an approximate 3-1 ratio. CD manifests and causes symptoms or illness when three things are present. First, there is a genetic predisposition involving specific genetic markers known as HLA-DQ2 and HLA-DQ8. Next, there is an event that triggers and activates the immune system. This trigger can be one of a variety of events, including illness, surgery, childbirth, stress or dietary changes. Finally, the disease requires the ingestion of wheat, rye or barley to cause the illness.

Celiac Disease

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