Welcome to another e-newsletter from Three Rivers Endoscopy Center. Our physicians and nurse practitioner provide this information to help improve awareness in matters of health and nutrition. Each issue focuses upon a particular topic that we feel will be of interest.

This issue was written by Dr. Ernest Stanley who is a Gastroenterolgist on staff at Three Rivers Endoscopy Center. The topic presented by Dr. Stanley is Celiac Sprue. Although this condition is fairly common in this country, chances are you have probably never heard of it. In fact, odds are good that you know someone who has it, even if they don't. We all think of bread as the "staff of life." Sometimes, it is the opposite. Read on...

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First, Some Anatomy...
You may think that you feed your gut. Actually, your gut feeds you. Most of the food you eat would be as deadly as poison if it got directly into your bloodstream. Your gut can best be described as a very elaborate food "disassembly" plant. Except for dietary fiber - nut husks, bran, celery strings and such - your gut disassembles virtually everything you eat into smaller components that your body can use.

Your gut converts the crisp fat in your breakfast bacon into smaller fatty acids. It turns the protein in your dinner lamb chop into smaller amino acids. It changes the large carbohydrates in your mashed potatoes into sugary glucose. Then it passes these much simpler nutrients to your blood system.

To maximize absorption of nutrients into your bloodstream, the walls of your small intestine are normally covered with microscopic hair-like projections called villi and even smaller microvilli. Villi contain special cells which enable absorption of nutrients into your body. Each square inch of intestine contains about 10 billion microvilli. This increases the surface area for food absorption dramatically. In fact, if your intestinal interior were smooth, it would present only about 6 square feet of absorptive surface. Instead, because of these villi, it presents about the same surface as a football field!

Baking Bread
Bread is a mainstay of most diets. Making bread involves a complex interaction between flour and yeast cells. Once activated, yeast begins feeding on the sugars in flour, and releases tiny bubbles of carbon dioxide gas. This would result in a bubbling brew without something to contain the carbon dioxide bubbles. Heres where flour comes in. There are lots of different types of flour used in bread, but the most commonly used is wheat flour. This is because wheat flour contains two proteins, glutenin and gliadin, which, when combined with water, form gluten. As you knead the dough, the gluten becomes more and more stretchy. This gum-like substance fills with thousands of gas bubbles as the yeast goes to work giving raised bread its porous, tender quality.

Celiac = Allergic Reaction
We usually think of bread as the "staff of life," but for people with celiac disease, some grains have just the opposite effect. Celiac disease (also known as celiac sprue and gluten-sensitive enteropathy) is a hereditary allergy to gluten - a protein found in wheat, barley, and rye. When susceptible people eat foods contains any of these three grains, an allergic reaction occurs which results in inflammation and destruction of the delicate intestinal villi. This is called an "autoimmune reaction" - one in which the body mistakenly attacks itself. With shortened villi, the surface is reduced to about the size of a basketball court or smaller, and the intestine cannot absorb nutrients properly. The consequence is poor absorption (so called malabsorption) of your food, vitamins and minerals. Thus, even though an individual with celiac disease may be eating normally, their body may not be getting enough nutrition.

Celiac disease is a very old disease and may have been first described in 250 A.D. A clear understanding of the cause did not occur until 1952 when a Dutch pediatrician noted that afflicted children gained weight during a famine when wheat was not available. Awareness of this condition has been low in this country. However, a recent increase in the diagnosis of celiac disease - likely due to a new blood test for the disease - has increased awareness amongst the medical community.

What Are The Symptoms of Celiac?
The problem is that symptoms can range from severe to none. In severe cases children may present with diarrhea, weight loss and failure to thrive. In adults the symptoms are often much more subtle - though the gut inflammation may still be severe. The symptoms may include occasional diarrhea, abdominal bloating, gas, fatigue, or simply intolerance to milk products. People with an itchy, blistering skin eruption affecting the knees, elbows, buttocks and back, called dermatitis herpetiformis, almost always also show evidence of gluten sensitivity on intestinal biopsy. Poor absorption of iron, folic acid, or both, can cause anemia; and failure to absorb calcium, vitamin D, and other nutrients can lead to osteoporosis. Recurrent sores in the mouth (apthous stomatitis) may be the only symptom in some patients. Patients often have vague symptoms and may not see a doctor for years.

What Causes Celiac?
Why an individual becomes "allergic" to gluten is unknown. However, there is definitely a genetic predisposition. Most individuals with this disorder are residents of Western Europe and places where Europeans emigrated, such as North America. In the past, it was felt to be a rare disorder affecting about 1 in 3000 individuals. With the advent of new, more accurate blood tests, it has been learned that approximately 1 in 200 Americans are affected, most of which are undiagnosed. Sprue is not contagious, but because of the genetic basis, approximately 10% of first-degree relatives (parents, siblings and children) are similarly affected.

Why Make the Diagnosis?
I have been asked this question by both patients and doctors. If the symptoms are mild or in some cases none, why bother looking for and diagnosing this condition? The answer lies in the common problems associated with long-term malabsorbtion. Because the fatigue and anemia develop gradually, people learn to live with these symptoms and they just assume the way they feel is normal. After proper treatment, it is not uncommon for the patients to relay how much more energy and vigor they have - "I just didn't realize how tired I was!". As mentioned above, long-term malabsorbtion of calcium can result in early and severe osteoporosis of the bones where even minor trauma results in fractures. Lastly, patients with untreated celiac are at significant increased risk of intestinal cancer.

How is the Diagnosis Made?

1. We have three tools to diagnose celiac sprue. The first diagnostic tool is to suspect the problem in the first place. As mentioned above, most adults present with vague and non-specific complaints. The diagnosis of sprue is often delayed due to the vague and diverse nature of the symptoms. A survey of 1,600 adult sprue patients done by New York's Columbia-Presbyterian Hospital found that on average, they took 11 years to be diagnosed.

2. When suspected, highly sensitive and specific blood tests are now available to screen for celiac sprue. The blood tests can be used to make the diagnosis and help monitor response to treatment. The most commonly used initial screening test is the IgA tissue tranglutaminase, or tTG. The accuracy of these blood tests is over 95%. Falsely positive readings are rare.

3. The most important test is to examine a tiny bit of tissue, known as a biopsy, from the surface of the small intestine. Today, this is most often accomplished by performing an endoscopic "scope" examination called a gastroscopy. Done under conscious sedation, this painless test allows the doctor to take several small biopsy samples of the intestinal lining for laboratory analysis. These small snips of tissue removed are examined under the microscope to see if the villi are damaged. CT x-ray or MRI scans do not help in the diagnosis.

How is Celiac Treated?
From a medical standpoint, the treatment for celiac disease is simple: Don't eat any food that contains gluten. But, this is easier said than done. Wheat, barley, and rye are found in an enormous number of foods - especially conveniently available breads, pastas, biscuits, cakes, pastries, breakfast cereals, beer, and most soups, sauces and puddings. Rice and cornmeal can stay on the menu, however. Avoiding gluten altogether requires a great deal of effort on the patient's part. This restrictive diet affects meal arrangements within the family and makes eating in restaurants and with friends difficult. Those who suffer, especially adolescents, feel different from other people, and restricted in their social life. Other patients with Celiac are the best resource on managing this disease for the newly diagnosed patient. Support groups are helpful. People with the disease share new information, such as where to buy gluten-free products. Intolerance to gluten is permanent and the diet should therefore be followed life-long as a permanent change in lifestyle.

Can Celiac's Live A Normal Life?
The good news is that celiac disease is much more detectable now, thanks to more accurate blood testing, and can be almost completely cured with a change in diet. Following a strict gluten-free diet for the rest of one's life requires enormous dedication and relentless detective work to uncover hidden sources of gluten. But when gluten is totally eliminated from the diet, improvement usually starts within days, and the small intestine is often completely healed (meaning the villi are restored) within three to six months. As long as they maintain a rigid dietary restriction of wheat and wheat products, Celiacs can live long and productive lives.

Recommended Links

• Celiac.com
  
• Gluten Intolerance Group
  
• Celiac Sprue Association
  
• Celiac Disease Foundation
  
• Greater Pittsburgh Celiac Sprue Support Group
  

Celiac Sprue Under the Microscope
This is a biopsy of normal small intestinal lining magnified thousands of times under a high-power microscope. Here you can see a cross-section of healthy villi which project upward - like slender fingers. It is billions of these small villi that dramatically increase the net surface area of the small intestine which maximizes nutrient absorption from our diet. When susceptible individuals with Celiac Sprue ingest grains containing gluten (wheat, barley, and rye), a reaction occurs in which the body is tricked into believing that these villi are foreign, like an infecting virus. The body mistakenly mounts a counterattack by mobilizing millions of white blood cells to attack the villi.	This microscopic photo is taken from a biopsy of a patient with Celiac Sprue before treatment. Here you can see that the normal finger-like villi have been eroded away. The surface is flattened. The numerous black dots reflect an increase in white blood cells which have come to attack the intestinal lining. This is a typical "autoimmune" reaction in which the body mistakenly attacks itself. By restricting gluten from the diet, the white blood cell attack diminished and the villi can grow back and restore normal absorption of nutrients. Unfortunately, gluten avoidance must be complete and life-long. If even a slice of bread is eaten, the villi are again destroyed.