1 Celiac’s Disease Chloe Bierbower Kelly Lonergon Brittany Pinkos Sarah Steinmetz

What is Celiac’s disease?  An autoimmune enteropathy triggered by the ingestion of gluten-containing grains in susceptible individuals resulting in intestinal damage  Disease of both malabsorption and abnormal immune reaction to the protein gluten  Main groups of proteins  Gliadins, glutenins and other alcohol-soluble proteins found in grains ž Also known as celiac sprue, nontropical sprue and gluten- sensitivity enteropathy

What is Gluten  Composite formed from several different proteins  Found most commonly in wheat and other related grains  Used in many processed foods as a thickener, binder, flavor enhancer and protein supplement

The Autoimmune response  CD is the result of inappropriate T cell- mediation  Glutenin and gliadin (GLU) derived peptides in native or de-amidated form act as antigens  Activates lamina propria to infiltrate CD4+ T lymphocytes isolated from intestinal mucosa from small intestine  Leads to the release of proinflammatory cytokines (in particular y-interferon) which cause profound tissue remodeling

5  Specific CD4+ T-cell responses to GLU peptides are due to genes HLA-DQ2 and HLA- DQ8  Possible to have 2 HLA-DQ2 genes, 2 HLA-DQ8 genes or one of each  2 HLA-DQ2 genes results in the highest susceptibility for CD  The occurrence of either of these genes does not mean a patient will develop CD The Autoimmune Response

CLinical research study  Study found that both adult and young patients with CD, regardless of which genes expressed, can respond to a diverse repertoire of GLU peptides  Still don’t know if a specific GLU protein triggers a specific immunologic response  responsehttp://glutenintolerance.net/Celiac- Gluten-Gliadin-Peptides-Multiple-Vader.pdf

7 Consequences of the autoimmune response  Immune reaction attacks and destroys small intestinal villi  Small intestinal villi aids in the absorption of nutrients  Without healthy villi the intestine cannot extract and absorb nutrients from food no matter the quantity of food consumed

Causes?  Unclear as of now  It is genetic  Sometimes triggered or becomes active after surgery, pregnancy, childbirth, viral infection or severe emotion stress  Some gene mutation increase risk  More common in people with type 1 diabetes, autoimmune thyroid disease, down syndrome, and microscopic colitis

What are the symptoms of CD?  Symptoms subdivided in typical or atypical forms  Vary with the age of the patient, duration and extent of disease and the presence of extraintestinal pathology  Can be completely asymptomatic

10 SYmptoms of CD  Typical form (Typically in infants 6-18 months of age)  chronic diarrhea  failure to thrive  abdominal distention  anorexia  muscle waisting

11 Symptoms of cd  Atypical form (more common in older children and adults)  dermatitis herpetiformis  iron-deficiency anemia  short stature  dentil enamel hypoplasia  arthritis and arthralgia  chronic hepatitis and hypertransaminaemia  osteoporosis  neurologic problems  other GI problems 11

Adults are less likely to witness normal symptoms but may experience instead….  Fatigue  bone or joint pain  Arthritis  Bone loss/ osteoporosis  depression or anxiety  Tingling or numbness in hands and feet  seizures  Missed menstrual periods  Infertility or recurrent miscarriages  Canker sores inside the mouth  Itchy skin rash called dermatitis herpetiformis

Why are symptoms varied?  Currently being studied  Could depend on length of time the person was breastfed  Age the person starting consuming gluten  Amount of gluten containing foods a person eats  Condition of the persons small intestine

A number of medical conditions are significantly associated with cd  Type 1 diabetes  Autoimmune atrophic gastritis  Autoimmune emocytopenic diseases  Autoimmune thyroid disease  Autoimmune liver disease  Rheumatoid arthritis  Addison’s disease  Sjogren’s syndrome  2-5% of patients with CD develop refractory CD, a serious complication associated with 50% risk of lymphoma development

Epidemiology of cd  Originally thought to be a rare childhood disease  Can be diagnosed at any age because CD may develop later in life  Over 2 million Americans have CD  Affects approximately 1 in every 133 Americans, similar European statistic  Global prevalence of CD is increasing

How is Celiac disease diagnosed?  Difficult to diagnose  Often mistaken for other diseases  IBS, Diverticulitis, intestinal infections  Histological and serological testing are essential  look for abnormalities in small intestine and presence of certain IgA autoantibodies  Positive diagnosis made when:  1. typical small-intestinal histopathological abnormalities defined as hyperplastic villous atrophy  2. clinical remission on a strict gluten-free diet with relief of symptoms within weeks

How is it treated?  Only known treatment is a Gluten- Free Diet  Complications Common for food presumed to be “gluten free” is contaminated Expensive Some medications and vitamins contain gluten  Supportive nutritional care with emphasis on iron and calcium

The Gluten free diet  Includes not eating foods that contain wheat, barley or rye and certain soy products  Products made from these include cereals, pasta, and many processed foods  Important to talk to chefs, waiters and pharmacists

Foods To avoid  Foods containing wheat, barely, or rye  Bulgar (several different wheat species)  Durum (species of wheat)  Farina (cereal food, cream of wheat)  Graham flour (whole wheat flour)  Semolina (purified wheat from durum wheat)  Spelt (ancient wheat species)  Triticale (wheat-rye hybrid)  Foods that contain these unless specified “gluten free”

overall most common physical Complications of cd  Malnutrition  Iron deficiency anemia  Loss of calcium and bone density  Lactose intolerance

21 psycho/social effects of CD  -Methods: 130 members ages of Celiac UK write narratives on living with celiac disease in response to “Please give a written account of your experience of living with coeliac disease”  -Results: 5 categories  1) Living with widespread ignorance  -can be undiagnosed for many years  -public ignorance  -self-education often a coping strategy  2) Social invisibility  -limited processed foods are gluten-free  -helped by clear labeling  -since eating is often a social activity, and very often CD is overlooked  3) Creating a coeliac community  -support from family and friends  -feel different from the community around them  4) A changed identity  -people’s reactions to when they don’t eat certain foods  -worries of dietary self-management  -social anxiety in terms of violating appropriate rules of politeness  5) Grief – and accepting the trade-off  -grief- response to diet restriction  -easier to make change to gluten-free diet if previously cooked  -trade-off- health can be restored 

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