Celiac disease - Causes, symptoms and treatment. MF.

Celiac disease( or gluten enteropathy, Guy-Herter-Geibner disease, non-tropical spruce, intestinal infantilism, flour disease) is an intestinal disease that has a genetic cause and is characterized by intolerance to the gluten protein and chronic inflammation of the small intestinal mucosa.

Gluten( gluten) is a protein contained in cereals( rye, wheat, barley, less oats).The protein contains L-gliadin, an alcohol-soluble glycoprotein that activates autoimmune aggression, has a damaging effect on the intestinal mucosa, causes inflammatory and atrophic processes and disrupts the absorption of nutrients in the intestine.

Celiac disease occurs at a frequency of 1: 300 - 1: 3,700. Women are almost twice as likely as men. The most common disease in America, Northern Ireland, Austria and Italy.

Causes of celiac disease

The cause of celiac disease is not yet fully understood, the main risk groups and triggers are highlighted.

1. Genetic predisposition is a defect of the enzyme gliadaminopeptidase, responsible for splitting gluten( in 10-15% of cases, heredity is traced, in twins up to 75%).

2. Immune disorders ( the disease is more reliably detected in people who already have an autoimmune pathology: type 1 diabetes, rheumatoid arthritis, herpetiform dermatitis, autoimmune thyroiditis, alopecia, scleroderma, as well as in patients with hereditary syndromes: Down, Turner andWilliams).

Another relative risk factor is the presence of other intestinal pathologies( congenital or acquired), as the sensitivity of cells to gluten increases.

Carrying out genes does not mean disease, it develops only in some carriers and for this, certain additional factors are often required. The starting factor can be pregnancy, deterioration in the course of autoimmune disease, acute viral infection, stressful situation, operative intervention in the intestine.

In children, the disease manifests itself most often with the introduction of complementary feeding of porridges, but it can manifest later, 5-6 months after the introduction of complementary foods or the initiation of artificial feeding by gluten-containing mixtures, sometimes after an acute respiratory viral infection, of intestinal infection. In some cases, the first manifestations of the disease appear at the age of 2-3 and even 10 years.

Symptoms of celiac disease

In celiac disease, the intestinal mucosa is affected, atrophy of the villi of the small intestine occurs, this leads to a disruption in the assimilation of nutrients from food. These processes and cause all the symptoms of the disease.

Symptoms of celiac disease in children

- weight gain is slow and does not correspond to norms,
- slow growth,
- curvature of spine,
- frequent regurgitation, vomiting,
- irritability, moodiness, episodes of aggression and apathy, lethargy,
- paroxysmal painsabdomen of stupid character,
- change in the character of the stool( its number increases, it becomes foamy, mushy, shiny and sharply unpleasant),
- chronic or intermittent diarrhea,
- edema,
- delay inrorezyvanii teeth early caries,
- intolerant of cow's milk,
- rickets,
- secondary immunodeficiency( special susceptibility to infections).

These symptoms can occur both individually and in combination. Further, girls may have problems with the formation of menstrual function, the probability of developing polycystic ovaries increases, in boys sexual dysfunction.

Symptoms of celiac disease in adults

- diarrhea up to 5-6 times a day, alternating constipation and diarrhea,
- admixture of blood in the feces, less abundant blood admixture caused by ulceration of the intestine with rupture of the vessel
- chronic anemia, less thrombocytopenia,
- coagulopathy( violation of clotting due to disturbancesuction of vitamin K),
- hypotension,
- bloating and rumbling( flatulence),
- cramping pains in the near-umbilical area,
- nausea and vomiting,
- weight loss, weakness,
- osteopenia and osteoporosis( bone fragility),
- hourcaries, aphthous( ulcerative) stomatitis,
- skin rash,
- skin dryness and flaking,
- spleen reduction in size,
- arthritis without deformities,
- gynecological problems( menstrual disorder, amenorrhea),
- impotence,
- hepatitis( inflammation of the liver), developed without an objective cause,
- migraine attacks, drowsiness, occasionally convulsive seizures, depression, numbness of hands and feet, panic attacks,

Atypical forms of celiac disease( nephropathy, endocrinopathies)ie difficult to diagnose. Latent( latent) celiac disease is almost imperceptible, with rare attacks of intestinal disorders without apparent causes, there are minor skin rashes. Difficult in diagnosis and this is dangerous.

Diagnosis of celiac disease

Diagnosis is complex, especially because they do not think about celiac disease and try to treat individual symptoms( arthritis, diarrhea, stomatitis).

Begin with a routine examination:

- A general blood test( in the OAB can be observed a decrease in hemoglobin, a decrease in the size of red blood cells), in the expanded analysis there is a decrease in T and B lymphocytes( protective cells responsible for different types of immunity)
- general urine analysisOAM)
- biochemical blood test( for celiac disease, cholesterol and protein can be decreased, glucose tolerance is impaired, ALT is increased, ASAT), and vitamin B12 content is reduced( its amount is reduced)
- coagulogram
- coprologic examination: little-developed yellow-brown or gray-yellow stool with undigested food residues, microscopically: fatty acids, soaps, the presence of starch grains and iodophilic flora
- microbiological examination of feces: a dysbacteriosis of varying severity, a decrease in the numberprotective strains of Escherichia coli, growth of hemolytic flora, lactone negative enterobacteria, proteus
- ultrasound of internal organs
- FGD

Densitometryotnosti bones).

This is followed by a specific diagnosis:

Stage I: combination of 3 main symptoms or 2 primary and additional - suspicion of celiac disease.

II stage - serological: increasing the level of antibodies of types M and G to gliadin and tissue transglutaminase( ATTG).The level of antibodies is measured before the appointment of a gluten-free diet. The material is venous blood.

High titres( 10-fold excess of norm and more) indicate a high probability of celiac disease.

The next step is the determination in the blood of AEMA( autoantibodies to endomisis) and HLA typing( genetic analysis, genetic typing with the search for defective genes).

The genes of the HLA system are responsible for distinguishing between one's own and other people's cells and are linked to the immune system. Of the entire set of HLA genes available for typing, HLA-DQ is important, seven variants of HLA-DQ( DQ2 and DQ4-DQ9) are now known.
About 95% of patients with celiac disease are hereditary DQ2 carriers( varieties DQA1 * 0501, B1 * 0201), or less frequently DQ8( DQA1 * 0501 or DQB1 * 0201).

These genetic markers are necessary, but insufficient conditions for the development of celiac disease and are found in about 30% of the population. Inheritance of the determining gene from both parents increases the risk of disease and the development of complications.

The reason these genes increase the risk of celiac disease is that the sensitivity to gliadin is increased, and thus the immune system is activated and the autoaggressive process is triggered.

The presence of genetic markers of celiac disease determines the high probability of disease, the absence of them - virtually eliminates the risk of disease.

Genetic testing for DQ2 / DQ8 should be performed for all patients with suspected celiac disease, as well as blood relatives of the person who has confirmed this diagnosis( the risk of inheritance in relatives up to 15%, depending on the degree of kinship, in twins up to 75%).It is also advisable to carry out genetic typing for people with the following diseases: insulin-dependent diabetes mellitus, hypoglycemic states of unclear origin( unexplained blood sugar lowering), juvenile rheumatoid arthritis, autoimmune thyroid diseases, hepatitis of unclear etiology, cardiomyopathy.

However, so far there is not enough data to introduce a population screening survey( ie 100% testing).

The positive results of all tests allow you to diagnose celiac disease and Stage III is not required. If the result is questionable, the next step is shown.

Stage III of the - instrumental: biopsy( taking a piece of mucous for microscopic examination) with detection of mucosal atrophy and characteristic morphological features.

With the technical impossibility of carrying out the second and third stages, it is recommended that a strictly gluten-free diet be prescribed for a period of at least 6 months( with a significant reduction in weight-bearing indices not less than 1 year) with dynamic supervision. With a good clinical effect, the abolition of the diet is not indicated.

Treatment of celiac disease

Diet

The main method of treating celiac disease is the appointment of a lifelong strict gluten-free diet. Caloric content should be twice as much as in healthy people of the same age group. The principle of mechanical and chemical shading is also observed. Food intake is 5-6 times a day.

Compliance with a life-long diet is difficult, but following several rules makes it easier:

- Prepare food at home, so you can reliably control all the ingredients, if you are forced to use the services of a cafe / restaurant, then choose only familiar dishes and, warning the cook about yourthe problem, ask about the composition of the dish. Since it's not about whims, but about the state of health, you will certainly go to meet.
- Buy products of proven brands and carefully read the labels on the product labels, some have the indication "does not contain gluten" and these are safe products, gluten can be contained in foods that include modified starch, dextrin, hydrolyzed vegetable protein, sauces and condiments.
- Now in many supermarkets there are special departments of products for patients with celiac disease, diabetes, and you can also try to order products via the Internet.
- If you cook for the family, then you should have a separate dish for cooking and eating food, carefully wipe the work surfaces before cooking to avoid contamination with wheat flour and other prohibited products, store your food separately in a closed container.
- Drinking alcoholic beverages is allowed in small quantities, rum, tequila, wine, cognac, gin are allowed.
- Some medicinal forms contain gluten, so always warn your doctor of any specialty about your disease( in the composition of the medim, festal, complim, allochol, the liquid form novopassita and others is included gluten).
- Gluten can be contained in cosmetics, for example in lipstick.

Excluded for celiac disease: wheat( including semolina and couscous), rye, barley, oats, bread of all kinds, pasta and instant noodles, confectionery( cakes, gingerbread, waffles, biscuits, drying), ice cream,some yogurts, many cheeses, sausages, canned goods, sauces, ketchup, vinegar, soy sauce, mayonnaise, candies with filling, caramel, some types of chocolate, corn flakes, instant coffee, tea and cocoa, concentrated soups and broth cubes, crab sticks, margarine, dishes in breading, all the productskta with dyes and preservatives, kvass, wheat and barley beer, wheat vodka, whiskey.

Prohibited foods with a gluten content of more than 1 mg per 100 g of product.

allowed in celiac disease: rice, millet, buckwheat porridge( before cooking grits must carefully sort out and wash as possible contamination of wheat under cultivation, storage and transportation), products made from rice, corn flour, soybean and potato starch, fruit, vegetables(including potatoes), vegetable fats, honey, meat, poultry, fish, eggs, caviar of low-fat varieties, tea, soft coffee, herbal teas, broth of wild rose, soups on light meat and fish broths.

At the beginning of treatment, the use of milk should be excluded or strictly limited, but further expansion of the diet and the inclusion of moderate amounts of previously prohibited foods are possible. From dairy products are best absorbed sour milk drinks and low-fat cottage cheese.

Drug treatment of celiac disease

- Enzyme preparations ( pantsitrat 1-2 capsules 3 times / day with meals, for children older than 6 years of drug applied by a doctor, the dose is determined individually, in a dosage of Creon 10000, 25000, 40000,the dose is determined individually depending on the severity of the condition, pangrol 10000 for 2-4 capsules with food intake, the duration of intake of all these drugs is determined individually).
- Vitamin therapy ( vitamins B1 and B6 subcutaneously, nicotinic acid / m or subcutaneously, the dosage individual)
- Treatment excess bacterial contamination ( Moving microbes) intestine( furazolidone 2 tablets four times a day 5-10 daysintetriks 2 capsules 2 times a day for 10 days under the control of a biochemical blood test, in particular hepatic enzymes, mexazal 1-2 tablets 3 times a day up to 2-3 weeks).
- Treatment of dysbacteriosis ( bifikol 3-5 times a day 2 times a day until 4-6 weeks, enterol for 1-2 capsules 2 times a day for 7-10 days).
- Treatment of anemia ( ferrous sulphate 0.5-1 grams 4-5 times a day immediately after meals, folic acid 5 mg per day for a long time).
- Calcium and vitamin D preparations ( selected individually).
- Treatment of depression ( treatment is selected individually).
- If within 3 months there is no positive response to a gluten-free diet, then a course of metronidazole( trichopolum) 1 gr should be performed.per day for 5 days and completely eliminate dairy products.
- If there is still no response to a diet or treatment started with severe clinical symptoms, the introduction of prednisolone 20 mg per day for 7 days is indicated.
- Refractory celiac disease requires a revision of treatment and prescription of immunosuppressors( dose and duration is selected by the gastroenterologist and strictly controlled during treatment).

Complications celiac

- development of ulcers of different depths in the gut, which may manifest gastrointestinal bleeding and perforation of ulcers,
- ileus,
- development of refractory( resistant to any therapy) celiac disease,
- infertility,
- displays all kindshypo- and beriberi,
- bone fractures due to osteoporosis,
- higher risk of developing cancer of the intestine disease( lymphoma and small bowel cancer, rarely esophageal cancer, stomach and colon),
- in pregnant womenThe risk of miscarriage, premature birth, birth of a small child and children with pathologies of the nervous system( due to a violation of absorption of folic acid) is increased.

Forecast

Clinical improvement is observed after a few days of adherence to a special gluten-free diet, a persistent improvement in 3-6 months. With a good adherence to a diet, the prognosis is relatively favorable, a gastroenterologist is required to be observed 1-2 times a year.

prognosis worsens when late onset of treatment, the development of refractory celiac disease, complications formation requires physician supervision and dynamic gastroenterologist, consulted other specialists( surgeon endocrinologist, obstetrician, urology, rheumatology, dermatologist).Mortality rates in patients not following a gluten-free diet are about 10-30%.Against the background of the diet, this indicator is less than 1%.

It should be remembered that gluten intolerance persists throughout life. Diet and treatment will only help remove the disturbing symptoms.

In the process of developing a new lifestyle you can help societies of people with the same disease, sites on the Internet, specializing in the supply of gluten-free products.

Therapist doctor Petrova A.V.