Coeliac disease – our answers to frequently asked questions

What is coeliac disease?

Coeliac disease, also known as gluten-induced enteropathy, is a chronic autoimmune condition that affects the body’s ability to digest gluten. Gluten is a protein found in, amongst other things, wheat, rye and barley – grains that are commonly used in many food products. In people with coeliac disease, consumption of this protein triggers a reaction from the immune system and the destruction of the intestinal villi, which are crucial for the absorption of nutrients. This leads to numerous deficiencies and health problems.

What are the symptoms of coeliac disease?

The classic symptoms of coeliac disease (mainly seen in children) include:

• oily or watery diarrhoea,
• weight loss, losing weight, symptoms of malnutrition,
• stomach ache,
• fatigue, lethargy,
• developmental disorders, mood swings, short stature, lack of muscle mass, loss of appetite, bloated stomach.

Non-classical, extraintestinal symptoms include:

• anaemia caused by a deficiency of iron, vitamin B12 and folic acid,
• high cholesterol, 
• elevated levels of transaminases (so-called liver function tests), 
• pancreatic diseases,
• mouth ulcers and ulcerative stomatitis, enamel hypoplasia,
• chronic fatigue syndrome, drowsiness,
• obstructive sleep apnoea, nosebleeds, sensorineural hearing loss
• neurological disorders (peripheral neuropathy – sensory disturbances and numbness in the limbs, coeliac ataxia – impaired motor coordination, dizziness, epilepsy, migraine headaches, so-called ‘brain fog’ – impaired cognitive function),
• depression, anxiety, eating disorders, psychosis, ADHD,
• early-onset osteoporosis, osteopenia and osteomalacia, frequent fractures,
• bone, joint and muscle pain, arthritis,
• kidney disease, IgA nephropathy,
• skin conditions: Dühring’s disease – the cutaneous form of coeliac disease, psoriasis, urticaria, atopic dermatitis,
• miscarriages, fertility problems, delayed puberty and early menopause in women,
• coexisting autoimmune conditions (type 1 diabetes, Hashimoto’s disease, joint, liver and skin conditions, etc.),
• deficiencies in vitamins and minerals (found in almost 90% of newly diagnosed patients).

How is coeliac disease diagnosed?

SEROLOGICAL TESTS

Diagnosing coeliac disease can be complex. Several methods are used for this purpose. Serological tests, i.e. blood serum tests, are the first line of investigation:

• total IgA antibody levels,
• antibodies against tissue transglutaminase (tTG), 
• anti-endomysial antibodies (EMA),
• antibodies against deamidated gliadin (DPG).

We do not need to carry out all these tests straight away. According to the 2020 guidelines from ESPGHAN (the European Society for Paediatric Gastroenterology, Hepatology and Nutrition), the first step should be to measure total IgA antibody levels and to test for antibodies against tissue transglutaminase.

If IgA levels are normal and there are no IgA-class antibodies against tissue transglutaminase, we can effectively rule out coeliac disease with 99% certainty. However, there are very rare cases where symptoms are present and further diagnostic tests are required.

SMALL INTESTINE BIOPSY

It should be emphasised that the absence of specific antibodies does not always rule out coeliac disease. According to the latest research, between 6 and 22% of people with coeliac disease do not produce any antibodies at all. Therefore, a small intestine biopsy is necessary for a definitive diagnosis. It is performed on patients with positive serological test results and can be used to determine whether the intestinal villi have been damaged in a manner typical of coeliac disease. The Marsh scale is used to assess the condition of the intestine:

An endoscopic examination alone is not sufficient to make a diagnosis, as damage to the villi can also occur as a result of other conditions.

EXAMINATION OF THE GASTROINTESTINAL TRACT USING A CROSBY CAPSULE

A Crosby capsule examination of the intestine, also known as capsule endoscopy of the small intestine, involves swallowing or inserting via a probe a small capsule equipped with a camera and a light source, which travels through the digestive tract, recording images of the inner surface of the intestine and taking samples. This method does not require sedation.

GENETIC TESTING

The sample used for the test is blood taken from the patient’s vein. The test is designed to detect the DQ2 and DQ8 genes. Genetic testing has clear advantages:

the test result is valid for life;

effectively rules out coeliac disease, saving the patient time and money on further tests for gluten intolerance, including regular repeat antibody tests;

the examination is painless and non-invasive;

You can also take this coeliac disease test whilst following a gluten-free diet.

It should be noted that a person who tests positive does not necessarily develop coeliac disease. The test helps to distinguish the condition from other gluten-related disorders.

Other gluten-related disorders

In addition to coeliac disease, there are other reasons for following a gluten-free diet. The most common include NCGS (non-coeliac gluten sensitivity) and wheat allergy. These reactions can occur through various mechanisms. 

Like coeliac disease, NCGS is a systemic condition whose symptoms are not limited to the gut. Conditions and symptoms linked by researchers to NCGS include: skin conditions, gluten-induced ataxia, gluten-induced neuropathy, encephalopathy, psychiatric disorders (e.g. depression), rheumatic diseases, fibromyalgia, and nutrient deficiencies caused by malabsorption and their consequences. Autoimmune diseases such as Hashimoto’s disease, psoriasis, type 1 diabetes and ankylosing spondylitis are also more common than in healthy individuals.

An allergy is an IgE-mediated reaction. It can be diagnosed using skin tests or blood tests. In the case of food hypersensitivity, the only reliable method is an elimination diet and observation of symptoms. It should be emphasised that the food intolerance tests currently popular on the market, which measure IgG and IgA antibodies, have limited diagnostic value, as positive results do not necessarily correspond to symptoms.

Who is at risk of developing coeliac disease?

It was once believed that only children were affected, but this view was based solely on the classic form of coeliac disease associated with malabsorption, which manifested itself in young children following the introduction of gluten into their diet. They experienced classic symptoms such as: chronic diarrhoea with very characteristic fatty stools, abdominal pain, abdominal distension, stunted growth, weight loss, anaemia and lethargy. 

We now know that anyone can develop the condition at any age, and diagnosis is made more difficult by the fact that coeliac disease can occur without these classic symptoms. What’s more, this non-classic form of coeliac disease is much more common. 

In adults with coeliac disease, the classic symptoms may differ from those seen in children. Weight loss is often not observed; instead, patients may be overweight or obese. Coeliac disease may co-occur with other autoimmune diseases and diabetes. Instead of chronic diarrhoea, patients may experience it only sporadically or suffer from bloating. Therefore, it is not possible to make a definitive diagnosis based solely on the symptoms reported by the patient. It is also very common for only the symptoms or conditions caused by coeliac disease to be treated, which does not yield long-term results. 

Given the wide variety of symptoms associated with coeliac disease, doctors from almost every specialism should take a closer interest in it: gastroenterologists, allergists, endocrinologists, gynaecologists, haematologists, rheumatologists, psychiatrists, neurologists, dermatologists, etc.

Can you develop coeliac disease at any age?

Yes, coeliac disease can occur at any age, in children, teenagers and adults alike. In some cases, symptoms may appear in early childhood following the introduction of gluten into an infant’s diet. In some people, coeliac disease may develop later in life, even in older adults.

How is coeliac disease treated?

The only effective treatment for coeliac disease is to eliminate gluten from the diet. Once diagnosed, patients must follow a gluten-free diet for the rest of their lives. Avoiding foods containing wheat, rye, barley and oats, and opting for safe food alternatives, will help reduce inflammation in the intestines and alleviate symptoms. People with coeliac disease should be under the care not only of doctors but also of a dietitian, who will teach them a new way of eating, ensuring that the gluten-free diet does not lead to nutritional deficiencies.

What should you avoid eating if you have coeliac disease?

In short – anything containing gluten, which is a protein found in cereals such as wheat, rye and barley. Oats, unless they are labelled with the crossed-out ear symbol (the gluten-free label), should also be considered a cereal containing gluten. Gluten-free grains include, amongst others: rice, maize, buckwheat, millet, amaranth, quinoa, teff and sorghum; however, to be 100% certain, all products should be certified. 

Supplementation is an important way to enhance your diet, and you should focus on:

• reducing inflammation,
• intestinal regeneration,
• to address nutritional deficiencies.

This is where our TGR – Comprehensive Intestinal Regeneration System – comes into its own!

Summary

In summary, coeliac disease is a digestive disorder caused by an intolerance to gluten. It can affect many aspects of health, so it is important to be aware of the symptoms and to consult a doctor if you suspect you may have it. Early diagnosis and the elimination of gluten from the diet are crucial for maintaining the health and quality of life of people with coeliac disease.