Celiac Disease

Overview of Celiac Disease

In general, celiac disease was originally considered largely a disease of white individuals, especially persons of European descent.

Comparatively, Its incidence has increased over the past 50 years. Moreover, Celiac disease has had several other names, including nontropical sprue, celiac sprue, adult celiac disease, also gluten-sensitive enteropathy. [1]

Epidemiology of Celiac Disease

Causes of Celiac Disease

The etiology of celiac disease is not known but following factors are mainly involved in this condition:

1. Environmental i.e.:

• One environmental factor is the clear association of the disease with gliadin, a component of gluten that is present in wheat, barley, also rye.

2. Immunologic i.e.:

• Critical also involves both adaptive and innate immune responses.
• Immunological factors

3. Genetic factors
4. Auto immune disease [1]

Types of Celiac Disease

1. Classical celiac disease:

Patients have signs and symptoms i.e.:

• Malabsorption
• Diarrhea
• Steatorrhea (especially; pale, foul-smelling, fatty stools)
• Weight loss
• Growth failure in children.

2. Non-classical celiac disease:

• Mild gastrointestinal symptoms
• Abdominal distension also pain
• Iron-deficiency anemia
• Chronic fatigue
• Chronic migraine
• Peripheral neuropathy (tingling, either numbness or pain in hands or feet)
• Vitamin deficiency (e.g. folic acid and B12)

3.Silent celiac disease:

• It is also known as asymptomatic celiac disease.
• Patients do not complain of any symptoms, but still experience villous atrophy damage to their small intestine. [2]

Risk factors of Celiac Disease

• A family member with celiac disease or dermatitis herpetiformis.
• Type 1 diabetes.
• Down syndrome or Turner syndrome.
• Autoimmune thyroid disease.
• Microscopic colitis (lymphocytic or collagenous colitis)
• Addison’s disease. (7)

Pathogenesis of Celiac Disease

Pathophysiology of Celiac Disease

Celiac disease is an immune-mediated enteropathy triggered by the ingestion of gluten-containing grains (wheat, barley, and rye) in genetically predisposed individuals. It is caused by an inappropriate T-cell–mediated immune response against ingested α-gliadin in gluten. The inflammatory process is limited to the small intestine and is characterized by the presence of intraepithelial lymphocytes, crypt hyperplasia, and varying degrees of villous atrophy. The loss of mucosal surface area leads to malabsorption of nutrients, resulting in diarrhea, flatulence, weight loss, and abdominal distention.

The majority of patients with celiac disease express the HLA-DQ2 allele, and almost all of the remaining patients express the HLA-DQ8 allele. These HLA molecules bind to deamidated gliadin peptides and present them to CD4+ T cells in the lamina propria. Activated T cells then produce proinflammatory cytokines, which attract other inflammatory cells and drive tissue damage. The intestinal mucosa also contains B cells that produce antibodies to gliadin and tissue transglutaminase (an enzyme that deamidates gliadin), which contribute to the pathogenesis of celiac disease.

The clinical severity of celiac disease is variable. Symptoms may manifest in infancy, childhood, or adulthood. In some individuals, celiac disease is asymptomatic or associated only with subtle signs such as anemia or osteopenia. In others, it can lead to severe malabsorption and malnutrition.

The diagnosis of celiac disease is confirmed by the presence of characteristic histologic changes on duodenal biopsy and the resolution of symptoms on a gluten-free diet. Serologic testing for antibodies to gliadin, tissue transglutaminase, and endomysium can aid in diagnosis. [14]

Early diagnosis and treatment of celiac disease are important to prevent complications such as osteoporosis, infertility, and an increased risk of certain malignancies.

Clinical Features

The classic presentation of celiac disease in adults includes

• Diarrhea,
• Flatulence,
• Weight loss,
• Abdominal distention, and fatigue.
• Diarrhea may be watery or semisolid, voluminous, and difficult to flush.
• Some patients have constipation rather than diarrhea.
• Steatorrhea is present in most patients who have diarrhea.
• Other GI symptoms include dyspepsia, nausea, vomiting, abdominal pain, and anorexia.

Extraintestinal manifestations include

• Anemia (most commonly iron deficiency),
• Fatigue,
• Osteoporosis or osteopenia,
• Sshort stature,
• Delayed puberty,
• Amenorrhea,
• Reduced fertility,
• Peripheral neuropathy,
• Dermatitis herpetiformis (DH),
• Aphthous stomatitis,
• Dental enamel defects,
• Elevated transaminases, and depression.

In children,

• Failure to thrive,
• Weight loss,
• Short stature,
• Abdominal distention, and muscle wasting are the most common manifestations.

Atypical or silent celiac disease may present with seemingly unrelated manifestations, such as iron deficiency anemia, fatigue, bone loss, elevated liver enzymes, neurologic symptoms, or DH. These patients may not have any GI symptoms.

The diagnosis of celiac disease is based on a combination of clinical features, serologic testing for celiac-specific antibodies, and histologic findings on duodenal biopsy.

Sign & symptoms of Celiac Disease

Patient of celiac disease is either asymptomatic or having symptoms for example,

• Malabsorption of multiple nutrients
• Diarrhoea
• Steatorrhea
• Weight loss [1]
• Constipation
• Fatigue
• Nausea also Vomiting
• Bloating also Gas
• Abdominal Pain [4]

Clinical examination of Celiac Disease

Appearance

The patient may appear pale and fatigued.

Skin/Mucous Membrane

• Dermatitis herpetiformis
• Alopecia
• Scaly dermatitis
• Easy bruise ability

HEENT

• Aphthous ulcers
• Chelosis
• Stomatitis
• Epistaxis

Heart

• Normal heart sounds

Lungs

• Normal bilateral vesicular breath sounds

Abdomen

• Pale, voluminous and malodorous diarrhoea.
• Hepatosplenomegaly
• Abdominal pain and cramping
• Abdominal distention
• Increased bowel sounds

Musculoskeletal

• Non-specific bone and/or joint pain
• Fractures – Osteopenia
• Tetany
• Decreased range of motion

Neurological

• Peripheral neuropathy(decreased sensations)
• Ataxia

Systemic

• Failure to thrive
• Stunted growth
• Fatigue

Extremities

• Pallor nails
• Edema (8)

Diagnosis of Celiac Disease 

• A small-intestinal biopsy
• tTG antibody test
• An increase in the number of intraepithelial lymphocytes
• Either Absence or a reduced height of villi
• A cuboidal appearance and nuclei
• Increased numbers of lymphocytes also plasma cells [1]

Differential diagnosis of Celiac Disease

• Increased intraepithelial lymphocytes are not specific
• Tropical sprue
• Prolonged post-enteritis syndrome
• Autoimmune enteropathy
• Common variable immunodeficiency
• Food allergy
• Crohn disease (9)

Complications 

the following complications of celiac disease:

Malabsorption and Nutritional Deficiencies:

• Anemia: Iron deficiency anemia is the most common, but folate and vitamin B12 deficiency can also occur.
• Osteoporosis and Osteomalacia: Due to impaired calcium and vitamin D absorption.
• Neurologic Complications: Peripheral neuropathy, ataxia, and seizures (rare) may develop.

Gastrointestinal Complications:

• Lactose Intolerance: Secondary to lactase deficiency from intestinal damage.
• Enteropathy-Associated T-Cell Lymphoma (EATL): A rare but aggressive malignancy.
• Ulcerative Jejunitis and Strictures: Uncommon but serious complications.

Other Complications:

• Infertility and Miscarriage: More common in women with untreated celiac disease.
• Dermatitis Herpetiformis (DH): An itchy, blistering skin rash associated with celiac disease.
• Short Stature and Delayed Puberty: In children with undiagnosed celiac disease.
• Increased Risk of Other Autoimmune Diseases: Such as type 1 diabetes and autoimmune thyroid disease.
• Refractory Celiac Disease: A small subset of patients who do not respond to a gluten-free diet.

Early diagnosis and adherence to a strict gluten-free diet can prevent or reverse many of these complications. [14]

Investigation of Celiac Disease

Most often use serologic tests and intestinal biopsies to diagnose celiac disease. If serologic tests suggest that a patient could have celiac disease, health care professionals should then order intestinal biopsies to confirm the diagnosis.

Genetic tests that confirm the presence or absence of specific genes associated with celiac disease may be beneficial in some cases.

Ordering serologic tests—blood tests that check for antibodies—is typically the first step in diagnosing celiac disease.

Serologic tests for celiac disease include:

• Tissue transglutaminase (tTG) immunoglobulin A (IgA) and tTG immunoglobulin G (IgG) tests
• Endomysial antibody (EMA) -IgA test
• Deamidated gliadin peptide (DGP) -IgA and DGP-IgG tests
• The serologic tests that check for IgA antibodies are more sensitive for celiac disease than the tests for IgG antibodies. However, in people who have IgA deficiency, IgG tests may be useful. For accurate diagnostic test results, a patient must be eating a diet that contains gluten.

tTG-IgA and tTG-IgG tests

• The tTG-IgA test is the preferred celiac disease serologic test for most patients.
• Research suggests that the tTG-IgA test has a sensitivity of 78% to 100% and a specificity of 90% to 100%.
• The performance of this test may depend on the degree of intestinal damage, making the test less sensitive in patients who have mild celiac disease. The test may also be less sensitive in children younger than age 2.
• The tTG-IgA test is most often an enzyme-linked immunosorbent assay (ELISA).

EMA-IgA test

• Health care professionals may use the EMA-IgA test after the tTG-IgA test to help make a diagnosis of celiac disease more certain. Research suggests that the
• EMA-IgA test has a sensitivity of 86% to 100% and a specificity of 97% to 100%. The performance of this test may depend on the degree of intestinal damage, making the test less sensitive in patients who have mild celiac disease.
• The test may also be less sensitive in children younger than age 2.

DGP-IgA and DGP-IgG tests

• The DGP tests are less sensitive and specific than the tTG-IgA test.
• However, health care professionals may order DGP tests in certain circumstances.
• For patients with IgA deficiency, health care professionals may order the DGP-IgG test.

IgA deficiency

• Although only 1 in 400 to 1 in 800 people in the general population have IgA deficiency, 2% to 3% of people with celiac disease have IgA deficiency.
• In patients with IgA deficiency, IgA-based tests—such as tTG-IgA—may not accurately detect celiac disease, and IgG-based tests can help with diagnosis.(10)

Treatment Celiac Disease

1. Firstly, Avoidance of wheat, barley, rye and oats in all forms brings about dramatic relief within weeks.
2. Seondly, Full recovery takes a few months to years.
3. Lastly, Apparent failure of therapy is due to inadvertent inclusion of the offending cereals in the diet.[5]

Prevention of Celiac Disease

1. Avoid all foods that contain wheat, barley, or rye.
2. Avoid foods manufactured or processed in the same facility as wheat, barley, or rye. These foods may have come into contact with gluten or contain small amounts.
3. Stick to eating gluten-free oats. Many oats are processed in the same facilities as wheat, barley, and rye.
4. Avoid consuming milk and milk products for some time after your celiac diagnosis. Taking a break from milk will give your intestine time to heal.
5. Read all food labels and ingredients carefully to spot gluten. Gluten is sometimes hidden in medicines and food additives and has a different name, such as "modified food starch." Your doctor, nutritionist, or dietitian may be able to give you additional tips on how to spot the hidden gluten in food and medicine products.
6. Steer clear of other household products that contain gluten. Always read the labels on products carefully before putting them in your mouth. Lipstick, envelopes, toothpaste, and mouthwash are other products known to contain gluten.
7. Consider sticking to a clean diet to ensure you avoid foods that contain wheat, rye, and barley. Fruits, vegetables, eggs, dry beans, fish, poultry, nuts, and seeds are some of many "clean" whole foods that are healthy and do not contain gluten.
8. Know about grains and starches you can include in a gluten-free diet. You can eat corn, quinoa, rice, buckwheat, and amaranth with celiac disease. (11)

Homeopathic Treatment of Celiac Disease

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.

Homeopathic Medicines for Celiac Disease:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicines:

Antimonium Crudum

• Specifically indicated in Celiac Disease. Head, aching from disordered stomach, especially from eating sweets or drinking acid wine. After a meal, dejection, lassitude, fullness tension; violent cutting pains. Accumulation of flatus in abdomen Headache with nausea.
• Moreover, Heartburn, nausea, vomiting. After nursing, the child vomits Its milk in curds, refuses to eat and is very cross. Gastric also intestinal complaints < bread and pastry, acids, sour wine, cold bathing, overheating, hot weather. Constant belching. Bloating after eating. Diarrhoea after acids, over eating, sour wine, baths. Slimy, purulent stools. Additionally, Diarrhoea alternates with constipation. Eczema with gastric derangements.
• Lastly, General weakness esp. night and on waking. Besides this, Emaciation or tendency to put on weight. Strong inclination to sleep in day. Better: open air, rest, moist warmth on the other hand, Worse: Heat, cold bathing

Pulsatilla

• Generally, Averse to fat food, warm food and drink. Eructations. Taste of food remains a long time, after ices, fruits, pastries. Pain especially, as from subcutaneous ulceration. Flatulence. Furthermore, Vomiting of food eaten long before. Gnawing, hungry feeling. Water brash with foul taste in morning. Abdomen painful, distended, also loud rumbling.
• Pressure as from a stone. Stool: rumbling, watery. Two or three normal stools a day. Irresistible sleepiness in afternoon. Wakes in morning languid, unrefreshed. Sad, cries readily. Symptoms ever changing. Worse: Heat whereas Better: open air

Arsenicum Album

• Long term debility, exhaustion, restlessness also abdominal symptomatology. Irritable weakness. Should be thought of where there is anaemia, degenerative changes, gradual loss of weight from impaired nutrition Odours from discharges is putrid. Besides this, Abdominal pains are gnawing and burning. Stool -small offensive dark.

Lycopodium

• It is especially indicated in Celiac Disease. For ailments gradually developing, functional power weakening with failure of digestive powers, where function of liver is seriously disturbed. For people intellectually keen but weak muscle power. Emaciation. Debility in morning. patient is thin, withered, full of gas and dry.
• Pains come and go suddenly. Dyspepsia due to farinaceous and fermentable food. Excessive hunger. Aversion to bread. After eating pressure in stomach. Eating ever so little creates fullness. Abdomen- full bloated, immediately after a meal.
• Lastly, Constant sense of fermentation. Belching. Better: Being uncovered, getting cold, warm food and drink on the other hand Worse: 4-8pm from right to left.

Iodum

• Rapid metabolism. Individual is exceedingly thin dark complexioned, enlarged lymphatics, has voracious appetite but gets thin. Additionally, Anxious and worried if does not eat. Diarrhoea, whitish, frothy fatty. Great weakness during menses. Thyroid enlarged. Goiter. Cutting pain in abdomen worse: When quiet, in warm room whereas Better: Walking about, in open air.

Podophyllum:

• In general, Chiefly affects small intestines, liver also rectum and duodenum. Diarrhoea of long standing. Stool watery, jellies like mucous, painless, profuse. Gushing and offensive. Furthermore, Constipation, clay coloured, hard, dry difficult. Abdomen distended. Rumbling and shifting of flatus in ascending colon.
• Nausea and vomiting Colicky pain. Depression of spirits. . Burning sensation especially, of tongue. Many troubles during pregnancy. Worse: Early morning, hot weather.[3]

Natrum sulph

• Good medicine for Celiac Disease. Duodenal catarrh; hepatitis; icterus and vomiting of bile; liver sore to touch, with sharp, stitching pains; cannot bear tight clothing around waist, worse, lying on left side.
• Flatulency; wind colic in ascending colon; worse, before breakfast. Burning in abdomen and anus. Additionally, Bruised pain and urging to stool. Diarrhoea yellow, watery stools. Loose morning stool; worse, after spell of wet weather. Besides this, Stools involuntary, when passing flatus, Great size of fecal mass.

China

• In detail, Tender, cold. Vomiting of undigested food. Slow digestion. Additionally, Weight after eating. Ill effects of tea. Hungry without appetite. Flat taste. Darting pain crosswise in hypogastric region. Milk disagrees.
• Hungry longing for food, which lies undigested. Lastly, Flatulence and belching of bitter fluid or regurgitation of food gives no relief worse eating fruit. Hiccough Bloated ness especially, better by movement.

Carbo veg

• In brief, Eructation, Heaviness, Fullness, also sleepiness, tense from flatulence, with pain; worse lying down. Additionally, Eructations after eating also drinking. Temporary relief from belching. Rancid, sour, or putrid eructations. Waterbrash, asthmatic breathing from flatulence.
• Nausea in the morning. Burning in stomach, extending to back and along spine. Pain as from lifting a weight; colic from riding in a carriage; excessive discharge of fetid flatus.

Kali carb

• This medicine is specifically indicated in Celiac Disease. Desire for sweets. Furthermore, Feeling of lump in pit of stomach. Gagging. Dyspepsia of old people; burning acidity, bloating. Gastric disorders from ice-water. Sour eructation, Nausea especially, better lying down. Constant feeling as if
• Sour vomiting; throbbing and cutting in stomach. Disgust for food. Anxiety left in stomach. Epigastrium sensitive externally. Easy choking when eating. Epigastric pain to back. Lastly, Pain from left hypochondrium through abdomen; must turn on right side before he can rise. [6]

References 

1. Harrisons_Principles_of_Internal_Medicine_19th_Edition-_2_Volume_Set
2. https://www.everydayhealth.com/celiac disease/guide/diet/
3. Homoeopathic Body-System Prescribing – A Practical Workbook of Sector Remedies
4. https://www.mayoclinic.org/diseases-conditions/celiac-disease/symptoms-causes/syc-20352220
5. Textbook of medicine
6. Materia Medica by Boericke W.
7. https://www.google.com/search?q=celiac+disease+risk+factors&rlz
8. https://www.wikidoc.org/index.php/Celiac_disease_physical_examination
9. https://surgpathcriteria.stanford.edu/gi/celiac-disease/differential-diagnosis.html
10. https://lompocvmc.com/blog/2060-what-causes-celiac-disease-and-can-it-be-prevented
11. Prevalence of celiac disease: a community based study from North India, ResearchGate, 2010
12. Robbins & Cotran Pathologic Basis of Disease (10th Edition, 2021, Kumar, Abbas, Aster)
13. Harrison’s Principles of Internal Medicine (21st edition, 2022, Jameson, Fauci, Kasper, Hauser, Longo, Loscalzo