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HomeLIFESTYLEFood & Kitchen SecretsLiving with Celiac disease- get your facts right

Living with Celiac disease- get your facts right

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Celiac disease (CD) is an immune-mediated systemic disorder elicited by gluten which is a protein in wheat and occurs in genetically susceptible individuals.

What is the incidence of Celiac disease?

It is common throughout the world and affects around one in 100 to one in 300 of the population. As per studies done in Northern India primarily in children, Celiac disease prevalence was at least 1 in 310while hospital-based studies examining a general pediatric patient population suggest a prevalence of 1 per cent. The risk of having Celiac disease is high in first-degree relatives (up to 10%), in people with diabetes and other autoimmune diseases, Down’s syndrome, and a number of syndromes.

Celiac disease: Risk for siblings  

In a study from North India the risk has shown as first-degree relatives are 8.2%, siblings 15.6%, parents 3.5% and offsprings 3%. However, in the west, it is 2.8 – 10 %. 

Approximately 6 to 8 Million Indians Suffer from Celiac Disease

The underlying pathophysiology of Celiac disease

The etiology of Celiac disease is multifactorial, with both genetic and environmental factors involved in disease development.

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Environmental factors – This includes diet, gluten and probably viral infections like adenoviral type 12 & 7, Rubella, Human herpes virus 1.  

Genetic factors – Susceptibility to Celiac disease is primarily associated with the human leukocyte antigen HLA-DQ2 allele. The heterodimer DQA1*0501 and DQB1*0201 is detected in up to 95% of persons with Celiac disease, with the remaining 5% expressing HLA-DQ8.  HLA DQ2 and /or DQ8 are necessary but not sufficient for the diagnosis of Celiac disease.

Immune factors – The pathogenesis of Celiac disease involves a CD4+ T-cell mediated immune response to gliadin peptides, activation of a CD8+ T-cell intraepithelial innate immune response, and production of antibodies against tissue transglutaminase, as well as anti-gliadin, anti-reticulin, and anti-endomysial antibodies.

The only treatment for Celiac disease is a strict gluten-free diet for life. No foods or medications containing gluten from wheat, rye, and barley or their derivatives can be taken – even small quantities of gluten may be harmful

Symptoms of Celiac disease

These can be divided into typical symptoms and atypical symptoms.

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Typical symptoms:

Chronic diarrhoea and its complications like malnutrition, weight loss, steatorrhea and oedema. The most common age of presentation is 6-24 months.

Atypical symptoms:

  1. Gastrointestinal symptoms: abdominal pain, reflux symptoms, vomiting, constipation, abdominal distension, bloating, borborygmus etc.
  2. Non-gastrointestinal symptoms
  • Liver : epatic steatosis, hepatitis recurrent abdominal pain
  • Neurological:  Epilepsy, Ataxia
  • Cardiac: Dilated cardiomyopathy , Recurrent pericarditis, Vasculitis
  • Dermatological: Dermatitis Herpetiformis , Alopecia , Psoriasis
  • Endocrinal: Hypo/Hyperthyroidism, short stature
  • Orthopediac: Arthralgia, Arthritis, Osteopenia / Rickets
  • Others: Recurrent abortions, Anemia, Myasthenia gravis

What’s asymptomatic Celiac disease?  

This was formerly known as silent Celiac disease. The patient reports no symptoms at all, even in response to detailed questioning, despite the presence of a characteristic intestinal lesion.

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However, studies on the effect of a gluten-free diet on patients who were asymptomatic at the time of diagnosis show improvement in their quality of life and thus support the decision to continue with dietary restriction in the long term.

How to diagnosis Celiac disease?

Diagnosis depends on:

Clinical features whether atypical or typical. High index of suspicion is needed in cases of atypical Celiac disease.

Serological blood tests: The various serological tests are:

  • Anti tissue transglutaminase (tTG) – It detects IgA-class antibodies against tissue transglutaminase (tTGA). The IgA recombinant anti-human tTGA ELISA assay is superior to the anti–guinea pig tTGA assay and is more cost effective than the endomysial antibody test. is considered to be the most sensitive method for detecting Celiac disease disease, with sensitivity approaching 97%. IgA tTG levels of 100 U or greater manifest severe degrees of villous atrophy (Marsh 3 lesions). It is false negative in young children and IgA deficient.
  • Antigliadin antibodies (AGA) – The anti-gliadin antibodies are no longer considered sensitive or specific enough to be used for routine clinical detection of Celiac disease disease, except in children younger than 18 months of age, because anti-gliadin IgA antibodies are considered to be the first autoantibodies to appear after intestinal exposure to a gluten-containing diet.
  • Antiendomysial antibodies (EMA) – Done by indirect immune-fluorescent assays. It is an IgA based antibody against reticulin connective tissue around smooth muscle fibres. It has high sensitivity and specificity (approaching 100%). Disadvantage is that it can be false negative in young children, operator dependent, expensive and time consuming and can be false negative in IgA deficiency.
  • Other serological tests includes  Endomysial antibody (EMA)  and Deamidated gliadin peptides (DGP).   Individuals with IgA deficiency are at higher risk for Celiac disease disease and in these individuals the tests can be false negative (EMA IgA & tTG IgA ). We should check IgA levels in all patients and should consider IgG based tests in IgA Deficiency( EMA IgG, TTG IgG)
  • Endoscopy and Small bowel mucosal biopsy: The characteristic findings on endoscopy include  Scalloped folds, fissures and a mosaic pattern, flattened folds and smaller size and/or disappearance of folds with maximum insufflations. Biopsies should be taken from bulb, D2 and D3 as there might be patchy involvement. Small-bowel biopsy remains the gold standard for diagnosing Celiac disease.  We use MARSH classification to describe the changes in histopathology. Changes include villous atrophy, crypt hyperplasia and an increase in intraepithelial lymphocytes.

How does one manage Celiac disease?

The only treatment for Celiac disease is a strict gluten-free diet for life. No foods or medications containing gluten from wheat, rye, and barley or their derivatives can be taken, as even small quantities of gluten may be harmful. Oats are not toxic in over 95% of patients with celiac disease, but there is a small subgroup (< 5%) in whom oats are not safe. In addition, there are chances of contamination with other grains.

Rice and corn (maize) can be part of a gluten-free diet. Complete removal of gluten from the diet of Celiac disease patients will result in symptomatic, serologic, and histological remission in most patients. Growth and development in children return to normal with adherence to the gluten-free diet, and many disease complications in adults are avoided.

Also Read: KNOW food allergy for NO food allergy

Approximately 70% of patients report an improvement in symptoms within 2 weeks after starting the gluten-free diet. With strict dietary control, antibody levels may decrease very soon after the diet has been instituted. In contrast, the complete histological resolution is not always achieved or may take years. Although most patients have a rapid clinical response to a gluten-free diet, the rate of response varies. Patients who are extremely ill may require hospital admission, repletion of fluids and electrolytes, intravenous nutrition and, occasionally, steroids and are described as having a celiac crisis.

Patients should be encouraged to eat natural high-iron and high folate foods, especially if a deficiency in these minerals is documented. Patients should consult a nutritionist, a doctor or a dietitian, who is knowledgeable about gluten-free diets.

Grains not permitted in CD

Barley, bran, gluten flour, graham flour, malt, malt extract, malt flavouring, malt syrup, oats, oat bran, oat syrup, rye, semolina, wheat germ, wheat starch, wheat bran.

Gluten-free grains allowed in a gluten-free diet

Amaranth, arrowroot, bean flours, corn, garbanzo beans, seeds, millet, nut flour and nut meals, oats (uncontaminated), potato flour, potato starch, rice, sorghum flour, soy flour, tapioca.

Other foods for a basic gluten-free diet

  • Milk, cream, buttermilk, plain yoghurt, fresh meats, eggs, legumes: lentils, chickpeas (garbanzo beans), peas, beans, nuts, seeds.
  • Fruits: fresh, frozen, and canned fruits no added and plain juices
  • Vegetables: fresh, frozen, and canned vegetables, liquid vegetable oils
  • A gluten-free diet is low in fibre. Patients should be advised to eat a high-fibre diet supplemented with whole-grain rice, maize, potatoes, and ample vegetables.
  • Any dietary deficiencies such as iron, folic acid, calcium and rarely vitamin B12 should be corrected.


Lifelong strict adherence to the gluten-free diet is the best way of reducing risk and protecting against nonmalignant and malignant complications, whilst improving the patient’s quality of life. Consultation with a professional team should take place every 3–6 months. Serological screening of first-degree and second-degree relatives should be considered.

Presently there is no other cure other than a strict gluten-free diet.  Several possible non-dietary targeted treatments are under trial but no definite drug is available till date.

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Dr Neelam Mohan
Dr Neelam Mohan
Dr Neelam Mohan is Director, Department of Pediatric Gastroenterology, Hepatology and Liver Transplantation at Medanta created at The Medicity Hospital – Gurgaon. She was conferred with the most prestigious “Dr B C Roy National Award” in medicine by Hon’ble President of India for her pioneering work in developing liver transplantation and pediatric hepatology in India. She was Co-chair of Standard Treatment Workflows (STWs) development in Pediatrics, endeavour by the Government of India (Niti Ayog) with the Indian Council of Medical Research in 2019 -2020 and Founder Chairperson of Women’s Forum of Global Association of Physicians of Indian Origin (GAPIO). She’s President of Commonwealth Pediatric Gastroenterology & Nutrition.


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