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Celiac Disease, Non Celiac Gluten Sensitivity, Wheat Allergy: What You Need to Know BCSLS Annual Congress Sidney, British Columbia Date

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Celiac Disease, Non Celiac Gluten Sensitivity, Wheat Allergy: What You Need to Know BCSLS Annual Congress Sidney, British Columbia Date Celiac Disease, Non Celiac Gluten Sensitivity, Wheat Allergy: What you Need to Know BCSLS Annual Congress Sidney, British Columbia date Ellen Bayens, The Celiac Scene with the support of the Calgary Chapter of the Canadian Celiac Association Used with permission . 1 Disclosure Canadian Celiac Association • National voice for people adversely affected by gluten. • Volunteer speaker The Celiac Scene • Resource for gluten-free living in Victoria, Vancouver Island & the Gulf Islands • Founder Do not reproduce without permission. 2 Learning Objectives Upon completion participants will be able to: Describe the basic physiology of celiac disease Identify the health consequences of CD Distinguish between celiac disease (CD), non- Celiac gluten sensitivity (NCGS) and gluten allergy (GA) Know where and how to find help for CD and NCGS 3 History of Celiac Disease First described in the second century • Cause not identified. Samuel Gee, MD - 1888 • First to link diet to Celiac disease treatment. • “If the patient can be cured at all, it must be by means of diet”. Dutch pediatrician, Willem Karel Dicke, MD - 1952 • Linked ingestion of wheat proteins as cause of celiac disease. Samuel Gee, MD Willem Karel Dicke, MD 4 Gluten Protein in wheat, barley, kamut, rye, spelt & few other grains. Elasticity, shape, binder. Made of two groups of proteins. • Gliadins, 12 subgroups • Glutenins, strength Gliadin = collectively called gluten 5 Celiac Disease (CD) Auto-immune disease; not a food allergy! Permanent intolerance to certain proteins collectively called “gluten” found in wheat, rye, barley, kamut, triticale. ~1% of the population-more frequent in families: • 8-15% of 1st degree relatives. (Parents, Children, Siblings) • 5-8% of 2nd degree relatives. (Grandparents, Grandchildren, Aunts, Uncles) Occurs at any age. Delayed diagnosis ➔ complications. Varied symptoms and severity Can be triggered in healthy, genetically predisposed people when additional stresses are placed on the body • childbirth, severe infections, surgery, food poisoning and emotional stress 6 The Process of Developing CD 3 factors - only AI disease where all factors known: • A genetic predisposition HLA DQ2, HLA DQ8 • Environmental (gluten) triggers abnormal immune response • Inflammatory response (tTG). Genes ➔ Gluten trigger ➔ Antibodies attack intestinal villi ➔ damage/ inflammation ➔ Nutrients not absorbed ➔ malnutrition/health problems ➔ Intestinal permeability increases (leaky gut) ➔Systemic response. 7 Intestinal Villi Normal Villi Flat Villi 22 Biopsy of Small Intestine - Normal Villi 22 Biopsy of Small Intestine from undiagnosed Celiac patient - Flat Villi 8 Celiac Disease and Auto-immunity Gluten binds to antigen presenting cell (APC) APC presents antigens Antigen=toxin or other foreign substance that induces an immune response in the body, especially the production of antibodies (AB). B cells produce antibodies (AB) AB destroy small intestine 9 Gluten on Small Intestine Villi- Do not reproduce without permission. 10 Symptoms & Deficiencies Classical Symptoms Abdominal cramping and pain Nausea and/or vomiting Intestinal gas and bloating Diarrhea, including steatorrhea Weight loss Deficiencies Iron deficient anemia Vitamin B12, folic acid, zinc Vitamin A, D, E,K (fat soluble) Protein, fatty acids 11 Symptoms Cont. Intestinal Non intestinal Weight gain Easy bruising Constipation Edema-hands/ ankles Lactose intolerance Osteoporosis, bone/joint pain, Oral ulcers (cankers) arthritis Abnormal liver enzymes Fertility problems, amenorrhea, impotence Depression Nervous system disorders – central and peripheral Extreme weakness and fatigue Migraines, alopecia and others... 12 Dermatitis Herpetiformis (DH) “Celiac disease of the skin”. Itchy, tingling, red, blistery bumps with clear liquid. Elbows, knees, buttocks, low back, back of neck. Continuous, comes and goes. Occurs in teens to 30s. May have intestinal damage, with or without other symptoms. Diagnosis: skin AB biopsy=celiac, even if no intestinal celiac symptoms. 13 Additional Symptoms in Children Dental enamel defects • may be the only symptom Delayed puberty Failure to thrive, delayed growth, short stature Abdominal distension Learning difficulties Irritability, behavioural changes Asymptomatic 14 Oral & Dental Manifestations Delayed eruption/ dental enamel defects Xerostomia - dry mouth Recurrent aphthous ulcers (canker sores) Cheilosis-cracking of the corners of the mouth. Oral Lichen Planus-chronic inflammatory mucous membranes Atrophic glossitis • Erythematous, edematous, smooth, painful tongue • B-vitamin, thiamin, pernicious anemia. Photo source: Children’s Digestive Health Photo source: AAFP.org. Harold T. Pruessner, M.D., Picture source: www.aaom.com/oral-lichen-planus, Picture source: www.nejm.org, Luca Pastore and Nutrition Foundation University of Texas Medical School at Houston The American Academy of Oral Medicine DDS, Rosario Serpico MD., New England Journal of Medicine, 2007 15 Celiac Associated Diseases/ Conditions Auto-immune disease Other • Hashimotos thyroiditis • Elevated Liver enzymes, • Rheumatoid arthritis • Intestinal lymphoma • Type 1 Diabetes Mellitis • IgA deficiency • Systemic lupus erythematosus • Down syndrome, Turner’s • Addison’s disease syndrome, Williams syndrome • Sjogren's • Epilepsy • Fibromyalgia • Sarcoidosis • Multiple sclerosis • Autoimmune hepatitis 16 Type 1 Diabetes & Celiac Disease Both are autoimmune diseases 90% time, diagnosis of T1D comes before a CD diagnosis 9, 13, 16, 17. Susceptibility to develop T1D and CD is largely inherited • share similar genetic origins 9, 11, 13, 18. 17 Type 1 Diabetes & Celiac Disease Symptoms Undiagnosed Type 1 Celiac Disease Diabetes Frequent Urination √ Unusual Thirst √ Extreme Hunger √ √ Weight Loss √ √ Extreme Fatigue √ √ Irritability √ √ Growth Failure (children) √ √ Table taken from csaceliacs/org 10 18 Diagnosis and Treatment Step 1 Refer to MD Step 2 Do not start gluten free diet before testing 10 grams of gluten/day for up to 8 weeks= 2 servings of gluten= four slices of bread/ day. Preliminary screening: serologic blood tests • IgA-tTg, IgA-EMA and DGP • Serum IgA-tissue transglutaminase testing (IgA-tTG) 86-89 % • Serum IgA-endomesial antibody testing (IgA-EMA) >90% • DGP is comparable to the tTG and reliable in young children and in the presence of IgA deficiency- not currently available in Alberta. • Genetic markers-HLA DQ2, HLA DQ8 Step 3 Confirmatory diagnosis: upper or intestinal endoscopy with biopsy= gold standard Step 4 Only treatment = Strict gluten-free diet for life If elevated AB after follow-up: diet not gluten free, cross reactivity 19 5 Criteria for CD diagnosis (ESPGHAN) 1. Symptoms compatible with Celiac disease 2. Positive serology 3. Presence of genetic markers – HLA-DQ2, DQ8 4. Intestinal damage following start of GF Diet 4 /5 of these crdetected by endoscopy/ biopsy 5. Symptom reduction iteria used to diagnose by some children's hospitals in Canada. (European Society for Pediatric Gasteroenterology, Hepatology and Nutrition) 20 What Happens to Celiac Patients When Glutened? Intestinal symptoms - immediate or delayed Non-intestinal symptoms - immediate or delayed No symptoms but intestinal damage ➔ other illnesses. Amount of gluten that causes symptoms varies • One crumb can make patients sick. FDA/Health Canada • 20ppm gluten = maximum content allowed in GF labeled food. 11, 21 21 20 ppm of Gluten: =1/2 teaspoon in a bath =Less than 1 drop in 2.0 tub filled with water (125 litres of soda litre bathtub) 23 Non-Celiac Gluten Sensitivity (NCGS) Many people can be gluten sensitive without biopsy proving CD. ~10% of general population. Fasano 6%, Ford 30% Symptoms are similar to CD symptoms. Currently, no reliable tests to diagnose NCGS. 23 Gluten Sensitivity=Intolerance= Food IgG Anti-bodies IgG anti-bodies attach to food; create antibody-antigen complex Removed by macrophages; can’t remove complex fast enough Complexes accumulate; deposit in tissues Inflammatory chemicals released NON-allergic (IgE)/ NON-autoimmune Complicated; IgG, enzyme deficiency i.e. lactose, other tests -ve Repeated exposure before symptoms Variety of symptoms • Abdominal cramping & pain • Nausea, gas, bloating, diarrhea, weight loss • Fatigue, headaches, peripheral paresthesia Anemia & deficiencies: iron, folate, B12, A,E,K,D Treatment: stop offending food➔ relief FODMAPS – fermentable oligosaccharides, disaccharides, monosaccharides, polyols 24 Gluten Allergy = IgE Anti-bodies (AB) Immunoglobulin E-IgE antibodies 1-2% of population AB created-remembers food AB binds to food-histamine released Can affect organs Tiny amounts Hives, swelling (face, lips, tongue, throat), tingling mouth, sneezing, difficult breathing, n/v/d, cramps, low blood pressure Seconds to one hour Wheat, milk, eggs, peanuts, tree nuts, soybeans, shellfish, fish Treatment: avoid, “Epi pen”, Benadryl 25 Lactose Versus Casein and Whey Lactose intolerance (sugar) Casein and Whey • Can be associated with CD intolerance or allergy • Damaged villi lose ability to (protein) produce lactase ➔lactose • Not associated with CD intolerant • Not impacted by introducing • Can improve when the gut GF diet. heals after introducing GF diet 26 Recap! Celiac=Auto-immune • Remove gluten for life. Sensitivity=IgG antibodies • Remove gluten, temporary? Allergy=IgE antibodies, histamine release • Remove gluten, treat with medication upon exposure 27 The Canadian Celiac Association
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