Celiac disease is an inflammatory small bowel disease induced by the intake of wheat, rye and barley in people with a genetic predisposition, also called celiac sprue, non-tropical sprue and gluten enteropathy.
The emergence of the disease dates back to the Middle East, Mesopotamia and Anodoli lumps, where agriculture began about 10,000 years ago, together with the history of humanity.
For the first time, Aretaeus of Cappadocia mentioned a picture similar to celiac disease in his books written in the first century BC.
It cannot be explained where and when the history of the disease began, whether it happened after wheat and other grains were introduced into the human diet.
The definition of the disease as it is known today was first introduced by the English pathologist Samuel Gee in 1887-1888, and then the relationship between the disease and gluten was found by Willem – Karel Dicke 2 . It happened during World War II (1941-1950). Although the disease was seen especially in European-born Caucasians in the 1950s, it was noticed that it was seen with similar frequency in all parts of the world with the detection of disease-related antibodies in the blood in the 1970s. Currently, the Pacific Islands, eastern China, and Japan are areas where the disease is rare.
This is thought to be related to eating habits. The prevalence of the disease in screening studies draws an increasing curve all over the world. While the average frequency is 1/100 in European-origin populations, it was found between 1% in children and 0.8-1.3% in adults in regional studies conducted in our country. In addition, it was found most frequently in Western Sahara Africa as 5.6%, contrary to the previous information.
Studies show that the disease increases with age and is more common in women than men. In addition, the frequency is 10 times higher in identical twins and among first-degree relatives.
Since it is an autoimmune disease, there is an increased risk in cases with type 1 diabetes, thyroiditis, Addisson’s disease, osteoporosis, Down syndrome and Ig A deficiency. 10% of patients diagnosed with irritable bowel syndrome have celiac disease.
Although genetic factors have an important role in the formation of the disease, environmental factors are also important. After gluten is not included in the diet due to wheat, the disease does not occur.
For this reason, the incidence of the disease is increasing in societies where wheat has an important place in their diet or in societies that have not had this disease before due to changing dietary habits.
Among these cereals, only the toxic effect of oats is controversial.
Wheat is similar in structure to rye and barley. Therefore, it creates a toxic effect on rye and barley. Oats, which differ in structure, are rarely toxic. However, it is still not very reliable.
The inner surface of the small intestine of affected individuals develops different responses to these substances (gluten and gliadin).
These formations stimulate limited defense cells and tissue enzymes in celiac patients. Thus, a kind of inflammation initiated by the patient on the surface of the small intestine as a result of stimulation of his own defense cells causes destruction on the inner surface of the small intestine.
The disease is common among first-degree relatives, susceptibility to gluten sensitivity (can be diagnosed by genetic encoding.
This genetic coding has been determined in more than 90% of those with celiac disease. The incidence of genetic variability in the healthy control group is It is 20-30%
The duration of exposure to gluten is directly proportional to the time of onset and development of the disease.It has been found beneficial in many studies to give breast milk for a long time and to start complementary foods while breastfeeding
Environmental factors such as viral infections, smoking, and food additives are thought to have a negative effect on the formation of the disease.
The recommended ideal for today is to give breast milk for a long time and to start additional foods with grains while breastfeeding between the 4th and 7th months.
CLINICAL IMAGE OF CELIAC DISEASE
Become a celiac disease clinic It can be quite different and variable. The symptoms of the disease related to the digestive system and other systems are largely due to the malabsorption that develops in the first part of the small intestine.
Fatty, dull-looking, more frequent and abundant stools than usual is the most important indicator of this disease. However, typical disease symptoms are less common in infants.
In addition, even patients with very mild findings can be diagnosed with blood tests.
A large number of patients without complaints can be noticed in community screenings.
1-Classical Celiac Disease
Mostly infants and young children aged 6-24. It is characterized by growth and development retardation, chronic diarrhea or loose stools, vomiting, abdominal pain, abdominal bloating, muscle weakness, muscle control difficulties, loss of appetite, and gastrointestinal system
symptoms, which occur with the addition of gluten to the diet during the months of pregnancy.
The disease can occur within weeks or months. Diarrhea is still the most common finding, it can be acute or insidious.
The growth and development of these children is retarded according to their age. Due to vitamin D and calcium deficiency, they are often diagnosed with rickets. These children, who may also have neurological findings, may be emotionally withdrawn, restless, unhappy, and moody.
2- Non-Classical- Atypical Celiac Disease
It is mostly seen in older children and adults over the age of 5-7.
Short stature, delayed puberty, tooth enamel layer disorders, aphthous stomatitis, iron deficiency anemia unresponsive to treatment or unknown cause, osteoporosis and bone weakness, chronic joint complaints, heart muscle disorders such as cardiomyopathy, abnormal liver tests There may be atypical complaints such as recurrent abdominal pain, nausea, vomiting, bloating, gastric esophagus reflux, as well as findings such as neurological disorders.
In young adults, there may be findings such as skin rash, redness, urticaria, and vitiligo alopecia. Most individuals with atypical findings and complaints do not have digestive system findings. Adults with unexplained iron deficiency have the disease more often than children. Increasing age increases the frequency of thyroid disease and neurological findings.
3-Silent Celiac Disease
It is the accidental detection of the disease in a healthy-looking child or adult while being screened. These cases are symptom-free. Therefore, the so-called risk group should be screened. In this group, the disease is seen at a rate of 4-5%.
In recent years, it has been shown that most of the silent celiac patients have mild symptoms of disease and some psychiatric changes. Therefore, it would not be entirely correct to call these phenomena silent. It is predicted that there are 7 silent cases compared to 1 case with complaints.
4- Potential Celiac Disease
Although blood tests are positive, small bowel biopsies are normal or slightly different. Although there are no findings before, they carry the risk of becoming a typical disease in the following years. They must be watched.
WHO SHOULD TEST?
It has not been determined exactly who will be tested in patients without complaints. However, the following groups should be screened;
– loss of appetite
– persistent, chronic diarrhea
– chronic constipation
– recurrent abdominal pain and vomiting
– loss of enamel on permanent teeth
– short stature
-significant delayed puberty
-anemia
-bone resorption
– high-risk groups
HOW IS THE DISEASE DIAGNOSED?
The diagnosis of celiac disease must be definitive. Because it is a lifelong disease and its treatment is lifelong. The diagnosis of the disease is based on the presence of characteristic changes in the small intestine biopsy and improvement with a gluten-free diet.
Blood tests
are useful in supporting the diagnosis of celiac disease, screening risk groups, and evaluating response to a gluten-free diet. The specificity and sensitivity of these tests are variable.
Genetic studies should be performed in patients whose diagnosis is hesitant.
Food intolerance tests are not used to diagnose celiac disease. Food intolerance or food allergy describes completely different diseases, it is not related to celiac disease.
TREATMENT IN DISEASE
Treatment is a gluten-free diet that will last a lifetime. Strict adherence to this treatment is important for the course of the disease. There is no alternative treatment yet.
Efforts to introduce less immunological grains such as Ethiopian grain, millet, sorghum and buckwheat into the diet continue.
The main grain group in the diet is corn and rice. However, in recent years, gluten-free wheat flour has been included in the diet. Early participation in the celiac disease solidarity group provides benefits in adaptation. A lactose-free diet is important because of the lactase deficiency that often accompanies symptoms until the symptoms resolve.
All patients should be screened for mineral and vitamin deficiencies, and bone mineral density should be measured. Deficiency should be replaced with treatment. All women of childbearing age should take folic acid. In addition, psychological support to patients and their dependents is an important part of the treatment.
In 90% of patients who start a gluten-free diet for celiac disease, clinical improvement begins after 2 weeks of diet. The most common cause of unresponsiveness to treatment is gluten leakage in the diet. Other causes may include infections, pancreatic insufficiency, food allergies, and other
types of colitis.
A small percentage of patients may have permanent intestinal structure changes despite proper diet, no other reason can be found. Celiac patients have an increased risk for bowel lymphoma, small bowel cancer, esophageal cancer and pharyngeal cancer, and they should be followed up.
