It is observed that some people are sensitive to certain food substances. This condition is known as ‘Intolerance’ since they develop allergic reactions on consumption of these substances. It is mostly found in cases like consumption of lactose present in the milk (lactose intolerance) and gluten present in the wheat (gluten intolerance). This condition needs to be diagnosed and special diets that are free of these substances need to be given to such people.
What is Gluten Enteropathy?
The word enteropathy means a disease of the small intestine. Gluten enteropathy is a medical condition where a person’s body cannot tolerate protein gluten present in wheat, oat, rye and barley which leads to damage of the small intestine. Gluten is also found in lipsticks, vitamins and medicines. The body cannot digest or breakdown gluten and develops sensitivity or intolerance towards it. Ingestion of gluten triggers autoimmune reaction wherein antibodies are produced against this protein during its absorption in the intestine. The inflammatory reactions, which occur, cause damage to the villi lining the small intestine. When these villi are damaged the nutrients (such as fats, iron, calcium and folate) cannot get absorbed and leads to malnutrition. Some people with gluten intolerance have mild sensitivity towards it, while others have severe gluten intolerance.
Gluten enteropathy is also known as Celiac diseases, Gluten sensitive enteropathy (GSE), and Celiac sprue.
Signs and Symptoms of Gluten Enteropathy
The symptoms of gluten enteropathy usually involve the intestines and digestive system, but they can also affect other parts of the body. The signs and symptoms of gluten enteropathy differ in their presentation and intensity, which includes:
- Abdominal discomfort
- Diarrhea and bloating
- Loose bowel movements
- Weight loss due to malnutrition
- A severe skin rash called dermatitis herpetiformis
- Musculoskeletal problems such as muscle cramps, joint and bone pain
- Growth problems and failure to thrive
- Osteoporosis due to decreased absorption of calcium and Vitamin D
Other symptoms of gluten enteropathy, which occur due to the primary symptoms are malabsorption related problems such as anaemia and fatigue. In children, the symptoms are different from adults and are characterized by abnormal growth and delayed development.
Epidemiology of Gluten Enteropathy
Gluten enteropathy was once thought to be a rare disorder with prevalence rate of 1 in 500. However, the current blood donor screening has shown relatively high incidence of 1 in 133 and in European countries, its prevalence is as high as 1 in 100. Thus, with better diagnostic methods the overall prevalence of gluten enteropathy is very high.
Prognosis of Gluten Enteropathy
Often gluten enteropathy is undiagnosed or misdiagnosed. The person continues with gluten containing diet and it causes more damage to the intestine. If not diagnosed in time, it can lead to serious complications. When diagnosed, it is immediately treated with gluten free diet as a life-long therapy, and then most of the symptoms disappear. It enables person suffering from gluten enteropathy to lead a normal healthy life.
It is a life-long disorder, if untreated it results in increased mortality and morbidity.
Causes of Gluten Enteropathy
Gluten enteropathy is known to occur due to genetic (HLA and non-HLA genes) and environmental (gluten) factors.
The exact cause of gluten enteropathy is not known. It is an autoimmune disease where the body’s antibodies recognize gluten protein as a foreign substance and mount an attack on it when present in the intestine. This causes damage to the villi lining of the mucosa.
The development of gluten enteropathy has been strongly linked to genetic predisposition, although not all people with family history develop this condition. Gluten enteropathy is common with people with type1 diabetes, microscopic colitis, Sjorgen’s syndrome and autoimmune thyroid disease.
Pathophysiology of Gluten Enteropathy
Gluten enteropathy is triggered by ingestion of gluten (gliadin) in genetically predisposed persons. These proteins exert damaging effects since they possess a sequence HLA-DQ2 gene and are resistant to the breakdown of gluten by the gastrointestinal enzymes. They affect the intestinal permeability, which triggers an immunological response. Thus, pathogenesis depends on both genetic and environmental factors.
Risk Factors of Gluten Enteropathy
- Although, the exact mechanism of how these factors places one at a greater risk for developing Gluten enteropathy is not understood; these are definitely found to be present in a person with gluten enteropathy. They are as follows:
- An immediate family member with celiac disorder. According to a research study, if the parent or sibling suffers from Gluten enteropathy, then 1 in 22 people have a chance of developing this disease.
- Exposure to gluten before 3 months of age
- Major life event, emotional stress, pregnancy or surgery in people who are genetically predisposed.
- Type1 diabetes, thyroid disease, rheumatoid arthritis or other autoimmune disease.
- Genetic syndromes such as Turner and Down’s syndromes are associated with an increased risk for gluten enteropathy.
Complications in Gluten Enteropathy
Gluten enteropathy may lead to anemia and fatigue. This may cause damage to organs such as liver, bone and brain. It is associated with increased risk for fractures and osteoporosis. It can lead to miscarriage or infertility related problems. Aside from other autoimmune disorders, gluten enteropathy and celiac disease is associated with an increased incidence of lymphoma and cancer of the small intestine.
Diagnosis of Gluten Enteropathy
The diagnosis of celiac diseases is often delayed since many symptoms are non-specific. Often it is misdiagnosed as Irritable Bowel Syndrome. It does take several weeks before it gets confirmed.
The doctor first suggests physical examination and questions regarding medical or family history. This is followed by diagnostic tests such as:
- Serological analysis of IgA tissue, transglutaminase Antibody (IgATTG) and Endomysial antibody. Antibodies towards transglutaminase IgA is considered to be the best test for diagnozing this condition due to its high sensitivity and specificity, ease of use and quantitative capability.
- Measure levels of iron.
- A stool sample to detect presence of fat. Since presence of fat indicates damage to the intestine.
- Blood sample is screened for the presence of osteoporosis too.
- If the blood test is positive then to confirm the results, it is followed by an endoscopy or biopsy of the lining of the tissue of duodenum. A small piece of tissue is taken and observed under the microscope and the tissue is graded by using Marsh’s score.
- Genetic Testing Method: The individuals with DQ2 or DQ8 haplotype show gluten enteropathy; while absence of these excludes the possibility of this diseases.
Treatment of Gluten Enteropathy
There is no treatment or medicines available for gluten enteropathy. The person has to be on gluten free diet therapy for life-long. This approach enables to resolve most of the symptoms associated with gluten enteropathy. In most cases, the villi get healed within six months and they start absorbing the nutrients properly. Patients with gluten enteropathy should never consume gluten containing foodstuffs, since they can damage the intestine and it can restart the problem.
However, in small group of patients, the gluten-free diet fails to control the condition and its symptoms which includes abdominal pain as well as malabsorption. These patients should be checked for other bowel related symptoms too.
Prevention of Gluten Enteropathy
Gluten enteropathy, is an inherited or genetic-linked disease, hence its occurrence cannot be prevented. However, one can take precautions by following life-long diets restricted in gluten. The foods such as meat, fish, rice, beans, fruits and vegetables are all fine for people with celiac disease however they should be prepared without ingredients that contain gluten. Some restaurants offer gluten-free meals. There are stores, which provide gluten-free versions of pasta, pizza, and cookies. Strict adherence to the diet can prevent health problems like Gluten enteropathy. The person suffering from gluten enteropathy should examine the contents very well before buying and consuming and ensure that it is gluten free since often there is hidden gluten in foodstuffs. They should purchase the products, which are labelled as “gluten free” products.
The clinical characteristics of gluten enteropathy continue to evolve. Once considered as a rare disorder, Gluten enteropathy is seen to be more prevalent in the different populations ranging from mild to severe symptoms. Screening of gluten enteropathy has become easy with use of reliable antibody screening tests. The permanent consumption of diet free of gluten is the only remedy to survive. Following dietary adjustments, there is definite improvement in health which allows patients to lead a better life
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