Celiac Disease

breadCeliac disease (CD), previously believed rather rare, has increased over the past several decades.[8] CD occurs in some who possess certain genes (HLA DQ2 or DQ8) and consume wheat/gluten-containing products. While many in the US posses these genes and eat wheat, most never develop CD. Studies suggest a number of “triggering factors”: infant feeding (formula vs breast), method of birth (C-section vs vaginal), timing of introduction of gluten into the diet, season of birth, early childhood infections, family history of autoimmune disease, other serious congenital diseases and possibly other genes have all been implicated.[7] More recent studies suggest the microbiome (the normal flora/bacteria/yeast colonizing the intestines) may confer risk or protection; H. Pylori (bacteria) in the GI tract may decrease risk for CD (and asthma/atopic disease) development.[11] While not causative proof, this large study’s findings coincides with others correlating disease occurrence with frequent antibiotic use, particularly during childhood, which eliminates naturally colonizing GI tract bacteria.

In celiac disease, the body produces antibodies to a type of wheat protein known as prolamins, also found in barley and rye.[9] These prolamin proteins are very similar to proteins found on cells lining the small intestine; the antibodies thus “tag or label” the small intestine cell components as “foreign”. The antibodies signal the immune system to attack small intestine cells as if invaders (like bacteria or viruses). The small intestine looses its structure and gap junctions (connections between small intestine lining cells), holds water/swells, then fails to absorb food well (“gut is leaky”).

The classic results are weight loss, chronic diarrhea and vitamin deficiencies. The presentation may be more subtle or misdiagnosed as irritable bowel syndrome, lactose intolerance, or even inflammatory bowel disease (Chron’s or ulcerative colitis). Symptoms outside the GI tract occur as well: muscle aches, arthritis, dental enamel defects, osteopenia/porosis, skin rashes, short stature, delayed puberty, or infertility of unknown cause. Impaired absorption leads to iron, zinc, folate, vitamin B6 and especially B12 deficiencies. There may be neurological manifestations such as anxiety, headache, seizure, depression, or peripheral neuropathy.[10]

Basic CD testing includes blood work for antibodies: anti-gliadin antibody IgG and IgA (less sensitive/specific), anti-endomysial IgA, and anti-transglutaminase IgG and IgA antibodies. IgA is a class of antibody specifically protecting the GI tract mucous membranes; it is often low/deficient in CD patients, and, thus, may confound blood tests. Biopsy of gluten-exposed small intestine to look for loss of structure and gap junctions makes the formal diagnosis.

As with other autoimmune diseases, those with CD are at higher risk for other autoimmune disorders and some cancers.[7] Additionally, strong evidence linking CD and mood disorders is emerging. In 2004, one group demonstrated 75% of patients with untreated celiac disease demonstrated low blood-flow (hypo-perfusion on SPECT scan) to brain areas (frontal cortex/cingulate gyrus) associated with mood disorders like anxiety and depression. Those treating their CD and normal controls demonstrate this less often.[12]

Western treatment consists of gluten avoidance diet and vitamin replacement. This can be difficult for some, depending upon level of dependence on processed/commercially-produced food.

Traditional Chinese Medicine (TCM) has long recognized the phenomenon and associated conditions related what the West currently calls CD/gluten sensitivity. TCM views “Spleen Qi/Yang deficiencies” as the root of all of these findings/phenomena. “Spleen Qi”, or as some translate it, “Pancreatic Qi” encompasses most digestive (and many other) functions. When “Spleen Qi/Yang” are weak, digestion is incomplete, and the “Yang fails to transport Fluids”.  As this “Damp” accumulates in the gut, chronic diarrhea, gas, etc ensue, roughly correlating to the “leaky (swollen) gut” described above. Poor assimilation leads to “Deficient Blood” and “Deficient Kidney Yin and Qi”, resulting in vitamin deficiencies, unexplained anemia, infertility, and later, bony abnormalities.

Over time, “Damp” progresses to “Phlegm”, which correlates with occurrence of additional autoimmune diseases. The “Spleen System” also “controls” muscles: weak “Spleen Qi” leads to weak muscles and systemic “Damp” retention renders muscles tender and sore (this is also seen in fibromyalgia). “Phlegm” migrating to the periphery produces the leg numbness/peripheral neuropathy (“Bi Syndrome”) described above.

The latest manifestation of this process, “Phlegm Clouding the Heart Orifice”, or central nervous system (CNS), reflects the mood symptoms (sluggish CNS communication). Additionally, in TCM, “Phlegm” may mistakenly “coat” otherwise normal cells, and thereby tags them as “foreign” for immune system clearing. There is a gluten-sensitive ataxia (trouble walking –see section on Gluten Sensitivity) that demonstrates immune cell infiltration around the CNS. TCM would anticipate this phenomenon in advanced cases. (TCM defines this same process in MS, and in fact, those with MS demonstrate elevated anti-gliadin antibody levels).[22, 23]

Since TCM uses the tongue to aid diagnosis, tongue inflammation {glossitis) is particularly noted. “Spleen Damp” accumulates throughout the GI tract, producing tongue swelling and often teeth marks evident along tongue edges.

Body acupuncture and especially Chinese Herbal Medicine very robustly address these issues; in fact, they represent late manifestations of common imbalances. In addition to gluten abstinence, Ayurvedic dietary principles (eating easily digested foods) ease stress on the over-taxed small intestine and strengthen digestive “fire”.[2,3]

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These brief overviews of conditions represent distillations of basic and current medical reviews from the following sources:

[1] Conventional Medical Sources

“Harrison’s Principles of Internal Medicine: Volumes 1 and 2, 18th Edition”. Dan Longo Anthony Fauci, Dennis Kasper, Stephen Hauser, J. Jameson, Joseph Loscalzo. McGraw-Hill Professional; (July, 2011)

Medscape eMedicine Physician’s online resource. Various review articles:

Allergic and Environmental Asthma: an Overview of Asthma
William F Kelly III, MD  Associate Professor of Medicine, Uniformed Services University of the Health Sciences; Staff physician, Division of Pulmonary/Critical Care Medicine, Department of Medicine, Walter Reed National Military Medical Center

Allergic Rhinitis
Javed Sheikh, MD  Assistant Professor of Medicine, Harvard Medical School; Clinical Director, Division of Allergy and Inflammation, Clinical Director, Center for Eosinophilic Disorders, Beth Israel Deaconess Medical Center

Food Allergies
Scott H Sicherer, MD  Professor of Pediatrics, Jaffe Food Allergy Institute, Mount Sinai School of Medicine of New York University

Atopic Dermatitis
Brian S Kim, MD  Clinical Instructor, Department of Dermatology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania

Seborrheic Dermatitis
Samuel T Selden, MD  Assistant Professor Department of Dermatology Eastern Virginia Medical School; Consulting Staff, Chesapeake General Hospital; Private Practice

Jeffrey Meffert, MD  Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

M Scott Linscott, MD, FACEP  Adjunct Professor of Surgery (Clinical), Division of Emergency Medicine, University of Utah School of Medicine

Cholinergic Urticaria
Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

[2], [3]
  • “Acupuncture Energetics: A Clinical Approach for Physicians”. Joseph M. Helms. Medical Acupuncture Publishers; 1st Edition. (1995)
  • “Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists”. Giovanni Maciocia. Churchill Livingstone; 2 Edition (July, 2005).
  • “Diagnosis in Chinese Medicine: A Comprehensive Guide”. Giovanni Maciocia. Churchill Livingstone; 1st Edition (January, 2004).

4. “Chinese Scalp Acupuncture”. Jason Ji-shun Hao, Linda Ling-zhi Hao and Honora Lee Wolfe. Blue Poppy Press; 1st Edition. (November, 2011)

5. Ege MJ, Mayer M, Normand AC, Genuneit J, Cookson WO, Braun-Fahrländer C, et al. Exposure to environmental microorganisms and childhood asthma. N Engl J Med. Feb 24 2011;364(8):701-9. [Medline]

6. Tsai JD, Chang SN, Mou CH, Sung FC, Lue KH. Association between atopic diseases and attention-deficit/hyperactivity disorder in childhood: a population-based case-control study. Ann Epidemiol. Apr 2013;23(4):185-8. [Medline].

7. JPEN J Parenter Enteral Nutr. 2012 Jan;36(1 Suppl):68S-75S. doi: 10.1177/0148607111426276

8. Rubio-Tapia A, Kyle RA, Kaplan EL, et al. Increased prevalence and mortality in undiagnosed celiac disease. Gastroenterology.2009;137:88-93.

9. Thompson T. Gluten contamination of commercial oat products in the United States. N Engl J Med. 2004;351:2021-2022.

10. Häuser W, Janke KH, Klump B, Gregor M, Hinz A. Anxiety and depression in adult patients with celiac disease on the gluten free diet. World J Gastroenterol. 2010;16:2780-2787.

11. Am. J. Epidemiol. (2013)178 (12):17211730doi:10.1093/aje/kwt234

12. Addolorato G, Di Guida D, De Rossi G, et al. Regional cerebral hypoperfusion in patients with celiac disease. Am J Med. 2004;116:312-317.

13. Sapone A, Lammers KM, Casolaro V, et al. Divergence of gut permeability and mucosal immune gene expression in two glutenassociated conditions: celiac disease and gluten sensitivity. BMC Med. 2011;9:23.

14. Biesiekierski JR, Newnham ED, Irving PM, et al. Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol. 2011;106:508-514.

15. Yamini D, Pimentel M. Irritable bowel syndrome and small intestinal bacterial overgrowth. J Clin Gastroenterol. 2010;44:672-675.

16. Wahnschaffe U, Schulzke J-D, Zeitz M, Ullrich R. Predictors of clinical response to gluten-free diet in patients diagnosed with diarrhea-predominant irritable bowel syndrome. Clin Gastroenterol Hepatol. 2007;5:844-850.

17. Hadjivassiliou M, Grunewald RA, Chattopadhyay AK, et al. Clinical, radiological, neurophysiological and neuropatholgical characteristics of gluten ataxia. Lancet. 1998;352:1582-1585.

18. Hadjivassiliou M, Boscolo S, Davies-Jones A, et al. The humoral response in the pathogenesis of gluten ataxia. Neurology. 2002;58:1221-1226.

19. Dieterich W, Ehnis T, Bauer M, et al. Identification of tissue transglutaminase as the autoantigen of celiac disease. Nat Med. 1997;7:797-801.

20. Korponay-Szabo IR, Halttunen T, Szalai Z, et al. In vivo targeting of intestinal and extraintestinal transglutaminase 2 by coeliac autoantibodies. Gut. 2004;53:641-648.

21. Hadjivassiliou M, Maki M, Sanders DS, et al. Autoantibody targeting of brain and intestinal transglutaminase in gluten ataxia. Neurology. 2006;66:373-377.

22. Tengah CP, Lock RJ, Unsworth DJ, Wills A. Multiple sclerosis and occult gluten sensitivity. Neurology. 2004;62:2326-2327.

23. Hadjivassiliou M, Sander DS, Grünewald RA. Multiple sclerosis and occult gluten sensitivity. Neurology. 2005;64:933-934.

24· Lever R, MacDonald C, Waugh P, Aitchison T. Randomised controlled trial of advice on an egg exclusion diet in young children with atopic eczema and sensitivity to eggs. Pediatr Allergy Immunol. Feb 1998;9(1):13-9. [Medline].

25. Branum AM, Lukacs SL. Food allergy among children in the United States. Pediatrics. Dec 2009;124(6):1549-55. [Medline].

26. Fleischer DM, Burks AW, Vickery BP, Scurlock AM, Wood RA, Jones SM, et al. Sublingual immunotherapy for peanut allergy: a randomized, double-blind, placebo-controlled multicenter trial. J Allergy Clin Immunol. Jan 2013;131(1):119-27.e1-7. [Medline]. [Full Text].

27. Hand L. Probiotics may protect infants from allergy, but not asthma. Medscape Medical News [serial online]. August 19, 2013;Accessed August 25, 2013. Available at http://www.medscape.com/viewarticle/809604.

28. Elazab N, Mendy A, Gasana J, Vieira ER, Quizon A, Forno E. Probiotic Administration in Early Life, Atopy, and Asthma: A Meta-analysis of Clinical Trials. Pediatrics. Aug 19 2013;[Medline].

29. O’Connel RA. SPECT brain imaging in psychiatric disorders: current clinical status. In: Grünwald F, Kasper S, Biersack HJ, Möller HJ, eds. Brain SPECT Imaging in Psychiatry. Berlin: de Gruyter; 1995:35-57.

30. Grasby PM, Bench C. Neuroimaging in mood disorders. Curr Opin Psychiatry. 1997;10:73-78.