0(543) 254 1144
Celiac disease, the small intestine is a vital organ where digestion and absorption of nutrients take place. The length of the small intestine is 4.5m (4-5.5m), and 40% of it is formed by the duodenum and jejunum, and 60% by the small intestine called the ileum.
The absorption surface of the small intestine is approximately 200-300m2. This width in the area of the absorption surface is created by the folds of mucous lining the inner surface of the intestines and the millions of projections that can be seen under the microscope, called villi and microvilli.
Villi are extensions that protrude into the cavity of the small intestine, while microvilli are extensions of intestinal cells called enterocytes, about 1 micron in length and 0.1 µm in diameter, that can only be seen with a microscope (micron is one-thousandth of a millimeter).
In the small intestine, absorption occurs in the villi. Celiac disease (Celiac disease, Celiac sprue, nontropical sprue), also known as gluten enteropathy, is a disease that causes impaired absorption of nutrients from digested food from the intestines.
People with celiac disease are sensitive to ‘gluten’, a protein found in wheat, barley, rye and, to a lesser extent, oats. Gluten’s main reactant is gliadin.
When these people are fed with gluten-containing foods, as a result of the immunological reactions that occur in the part called mucosa, which is formed from the cells that cover the inner surface of the small intestine, the absorbent cells in this region are damaged.
(Immunological reaction; a type of inflammatory reaction produced by the body’s immune system). After this damage, the digestion and absorption of nutrients necessary for the body will be disrupted, and diarrhea and the deficiency of substances that cannot be absorbed from the intestines begin over time.
For this reason, Celiac disease is classified among intestinal diseases with malabsorption. When people with celiac disease are fed a gluten-free diet, the damage to their intestines improves, but if they start consuming gluten-containing foods again, the symptoms of the disease reappear.
Celiac disease is a genetic disease, defective genes that cause this disease can be passed on in families. Up to 10% of patients have other family members with celiac disease.
Surgical interventions, pregnancy, childbirth, some viral infections and severe mental distress may cause the disease to occur. It is less common in blacks and people of Asian descent. Although it can occur at any age, it is more common in children aged 8-12 months and between the ages of 30-40.
The true incidence of celiac disease is unknown. The increasing frequency of the disease and the widespread use of diagnostic tests may be responsible for the fact that the disease is more common than before.
The disease is most common in people living in northern Europe and North America. One out of every 100-150 people living in these regions has celiac disease.
The incidence in our country is thought to be 1/300. The incidence of celiac disease is increased in a first-degree relative with celiac disease (10%) and in identical twins (75%) of whom one is sick.genetik öğesini güçlendirmektedir.
Celiac disease occurs as a result of the combination of environmental (gluten) and genetic factors that trigger the immunological response in the body. In other words, for the formation of celiac disease, both genetic predisposition and contact with gluten, which is an environmental factor, are necessary.
When a person with celiac disease is fed a food containing gluten, the immune system accepts this substance as a foreign substance (a kind of allergy) and starts to produce some substances called antibodies against this substance through the body’s immune system ( such as anti-gliadin antibodies).
Since the immune system cells (lymphocytes) that become reactive to gliadin encounter gliadin, the immunological reaction is mainly located in the small intestine, and after this reaction, damage occurs in the small intestine mucosa resulting in absorption.
People with celiac disease find two other types of antibodies in their blood besides anti-gliadin antibodies. Unlike anti-gliadin antibodies, these antibodies are antibodies formed against the person’s own tissues.
One of them is ‘anti-endomysial antibodies’ against a substance found in the structure of absorbent cells (enterocytes) lining the inner surface of the small intestine, and the other is ‘anti-transglutaminase antibodies’ formed against an enzyme in the cell.
The presence of these antibodies indicates that autoimmunity plays a role in celiac disease. (Autoimmunity: The immune system in the body tries to damage or destroy the formations in the body’s own structure – a kind of self-recognition fault). Celiac disease manifests itself with different symptoms in children and adults. Developmental and growth retardation in children, short stature, may be early signs of celiac disease. Abdominal pain, nausea, vomiting, diarrhea, moodiness, behavioral disorders and failure in school are other symptoms that can be seen.
It can take years for symptoms to appear and become severe. Generally, there is a partial decrease in the severity of the symptoms during adolescence. Celiac disease in adults usually appears around the age of 30-40, but it can also be seen at older ages.
Diarrhea, especially after the intake of fatty foods, feeling of gas and discomfort in the abdomen, abdominal pain, inability to gain weight despite a good appetite, weight loss, fatigue, fatigue and joint pain, osteoporosis, neuropathy, ataxia (imbalance), depression, adulthood These are the main symptoms of celiac disease.
Some celiac patients may have no symptoms other than intermittent diarrhea and indigestion for years. Some patients may have been followed for many years with the diagnosis of irritable bowel disease. Menstrual disorders in women, inability to get pregnant, decrease in sexual power in men are other symptoms that can be seen rarely in celiac disease.
Diarrhea, etc. in some patients. Without any signs of a digestive system such as a digestive system, the disease may only manifest itself with iron deficiency and a related anemia.
Women with severe anemia during pregnancy should be investigated for celiac disease. Some patients may experience deterioration in liver function tests.
celiac disease should also be considered in liver function test disorders of unknown cause. In 3-5% of cases the disease is discovered incidentally during a scan (silent celiac disease).
The disease in cases with positive blood tests but normal or slight changes in small intestinal biopsies is called ‘potential celiac disease’.
These cases should be followed up due to the possibility of developing typical disease in the following years.
When celiac disease is not treated, deficiency of vitamins, minerals and other nutrients in the body occurs over time due to malabsorption in the small intestine.
Among these, anemia (anemia), which can be of varying severity as a result of especially iron, folic acid and vitamin B12 deficiency, is one of the most common findings.
In addition, as a result of impaired absorption of vitamin D and calcium, calcium levels decrease, osteoporosis and fractures, visual disorders and skin problems due to vitamin A deficiency, nervous system problems such as balance disorder and sensation defects due to deficiency of vitamin B derivatives, coagulation disorders due to vitamin K deficiency. and bleeding, muscle weakness due to lack of electrolytes such as sodium, potassium and magnesium, leg edema due to protein (albumin and other proteins) deficiency and weakening of the immune system are other findings that may occur.
Another condition that can be seen in celiac disease is a skin disease called dermatitis herpetiformis, which has a similar appearance to chickenpox, mostly presenting with itchy, rash and blistering lesions on the back, lower and upper extremities and buttocks.
In addition, some rheumatic diseases, thyroid gland diseases (Hashimato’s disease) and adrenal gland diseases (Addison’s disease), skin diseases such as psoriasis (psoriasis), intestinal diseases such as microscopic colitis can be found together with celiac disease.
When celiac disease is suspected, your doctor will ask you for some blood and stool tests after a thorough physical examination.
Measurement of blood levels of certain substances that may be deficient in this disease, such as calcium, magnesium, potassium, protein (albumin, immune globulins and coagulation factors), cholesterol, vitamin B12, vitamin A, folic acid and iron, and stool analysis as well as diagnosis of celiac disease Some side tests (serological tests) used in must also be done.
Anti-endomysial antibody (EMA), anti-tissue transglutaminase antibody (a-TTG), anti-deaminegliadin antibody (DGP) and anti-reticulin antibodies are serological tests currently used in the diagnosis of celiac disease.
The sensitivity of these serological tests in the diagnosis of the disease is high (80-95%). All antibodies have IgA and IgG subtypes and the important thing in diagnosis is that IgA subtypes are positive. These tests may be false-negative in individuals with IgA deficiency.
In general, 0.2% of the population has IgA deficiency, while 2% of patients with celiac disease have IgA deficiency. The positivity of IgG type antibodies should be considered in patients with IgA deficiency.
Serological tests may be negative in 6-22% of cases in celiac disease. In these patients, endoscopic biopsy should be performed for differential diagnosis.
Another examination that must be done in the diagnosis of celiac disease is to take a tissue sample from the duodenum, which is the first 40 cm part of the small intestine, with the help of an endoscope. The intervention for this procedure is not different from normal gastroscopy.
Biopsy is an indispensable diagnostic method and serological tests cannot replace biopsy for diagnosis. It is also possible to see structural changes in the small intestine mucosa during endoscopy.
After the tissue sample is stained with special methods, it is absolutely necessary to examine under a microscope and see the findings that may belong to this disease, both for the definitive diagnosis of celiac disease and for the differentiation of other diseases such as lymphoma that may be confused with this disease.
In celiac disease, it is recommended to take at least four biopsies from different parts of the intestine, since the involvement in the intestine can be patchy. Taking four or more biopsies doubles the chance of diagnosis.
Biopsies should be taken from more and more distal small intestine segments (jejunum) in patients with positive serological tests but normal findings in histopathological examination.
Positive serum antibodies and capsule endoscopy may be helpful in diagnosis in patients who do not want to undergo endoscopy. Observing the fine granular structure, called scalloping, formed in the duodenal mucosa in capsule endoscopy helps in the diagnosis.
If not diagnosed early, celiac disease can lead to serious problems. Those with complaints similar to the findings described above and/or those with a family history of celiac disease should consult a gastroenterologist.
Since celiac disease shows familial transmission, it would be appropriate to examine the relatives of the patients, at least with serological tests. Up to 10% of those with celiac disease can also have the same disease in their mother, father, sibling or children.
A strict gluten-free diet is the basis of treatment in celiac disease. For this purpose, foodstuffs made using gluten-containing grain products (wheat, barley and rye) should never be eaten.
Gluten-free oats can be consumed, but oats should not be eaten either, at least in the early stages of the disease, as they can often contain wheat particles.
Since oats contain soluble fiber, it is a type of grain that is recommended to be consumed because it lowers blood sugar and increases insulin response. Products made from rice, corn, potatoes and soy flour can be eaten.
Instead of regular flour, rice flour or corn flour and pastries made from them should be preferred. Corn syrup, sauce, etc. It can be used as a thickener in production. Since these patients may also have lactase deficiency (lactose intolerance), it should be recommended not to take milk and dairy foods initially.
There is no harm in eating fruits, vegetables, eggs and meat products, but wheat flour should not be used in the preparation of sauces. Alcoholic beverages and fruit juices can be drunk provided that they are not overdone.
Beer and whiskey may be tolerated in small amounts but should not be drunk if it triggers complaints. Since the application of a gluten-free diet is expensive, difficult and boring compared to normal nutrition, such a diet should not be recommended without a definitive diagnosis.
Today, various food products prepared for celiac patients are easily available from markets. The labels of the foods taken should be read carefully and should not be given to a celiac patient without investigating whether it contains a gluten-containing food item.
Gluten can be found in many products (salad dressings, instant puddings, etc.) that are sold on the market and are thought to be gluten-free. This is especially important since a celiac patient following a strict diet may encounter gluten one day (gluten challenge), which can lead to serious conditions.
The acceptable gluten amount in food products sold in markets and labeled gluten-free should be below 100ppm (1/4mg/kg) (ppm: parts per million).
According to the CAC (Codex Alimentarius Commission of WHO) gluten content in gluten-free products should not exceed 20ppm, which is considered safe for celiac patients.
This level is also considered safe by the FDA (American drug and food control committee, food and drug administration). Studies have shown that in celiac disease, less than 10mg gluten intake per day does not cause a toxic effect on the intestinal mucosa (2 slices of bread contains >3g gluten).
Consumption of 10-100mg gluten per day is considered safe in celiac patients. It is inevitable that intestinal mucosa will be damaged in the intake of 500mg or more gluten per day.
Days after starting a gluten-free diet, complaints begin to decrease. Clinical improvement usually occurs within 3-6 months. Despite the complete disappearance of the complaints, it may take as long as 2 years for the intestinal mucosa to heal completely.
There is no drug treatment for celiac disease. Corticosteroid therapy may be tried in patients who do not respond to a gluten-free diet. Patients who follow a strict gluten-free diet generally have a good course.
In untreated patients, the above-described findings will continue due to the persistence of intestinal malabsorption. In cases that do not respond to treatment, other diseases of the small intestine such as lymphoma should be investigated.
Since the risk of osteoporosis (bone loss) and fracture (fracture) is increased in celiac disease, patients’ calcium, magnesium, vitamin D and parathormone (PTH) levels should be monitored at regular intervals and bone density should be measured every 2-3 years.
Oral calcium intake should be at least 1000mg/day, and vitamin D deficiency should be corrected. Vaccination of patients against pneumococci, haemophilus and meningococci may be recommended, as the risk of infection due to encapsulated bacteria is increased in celiac patients due to hyposplenism (decreased spleen functions).
It should not be forgotten that celiac patients may respond inadequately to hepatitis B vaccination. In patients with vitamin and mineral deficiencies, the deficiency should be corrected with appropriate preparations.
Serious diseases that can occur in the long-term in untreated celiac patients are small bowel adenocarcinoma and a disease called lymphoma, which is a type of small bowel tumor.
The incidence of small bowel cancer and lymphoma in patients with celiac disease is three times higher than in normal individuals. In cases where a strict diet is applied, conversion to lymphoma can be prevented. Chemotherapy may be required in cases that develop lymphoma.
