Celiac Disease

Progressive weakness and fatigue for the past 6 months prompted a 43-year-old woman to consult her physician. She denied diarrhea, melena, hematochezia, cough, fever, and night sweats. Her skin and conjunctivae were pale.

Stool was brown and tested guaiac-negative. Laboratory data were remarkable for hemoglobin and ferritin measurements of 7 g/dL and 8 µg/L, respectively. An upper gastrointestinal endoscopic examination revealed abnormal duodenal folds characterized by a serrated border and loss of villi, pictured here. Biopsy of duodenal tissue disclosed loss of normal villous structure; the intestinal crypts were markedly elongated and opened to a flat absorptive surface. After 6 weeks of a gluten-free diet, the patient showed marked improvement.

Dr Klaus E. Mnkemller of the University of Alabama, Birmingham, reports that celiac disease (CD), or celiac sprue, is characterized by marked villous atrophy of the small intestine that leads to malabsorption of a variety of nutrients, including iron; folate; and fat-soluble vitamins, such as vitamins A and K. CD represents an abnormal immune response to gluten (specifically gliadin), a component of wheat, barley, rye, and some varieties of oats.

The clinical manifestations of CD are variable. Many patients may not have diarrhea or other gastrointestinal complaints; instead, they may demonstrate only extraintestinal symptoms such as iron deficiency anemia, osteoporosis, muscle atrophy, peripheral neuropathy, and dermatitis herpetiformis.

The diagnosis of CD depends on the demonstration of malabsorption, typical histologic features on small-intestinal biopsies, and response to a gluten-free diet. Appropriate treatment with a gluten-free diet results in significant clinical improvement and normalization of intestinal structure in the majority of patients who have CD.

We need to advise our patients with CD to avoid obvious sources of gluten, such as baked goods, wheat- or oat-containing cereals, and noodles or spaghetti. Emphasize that glutens, especially wheat flour, are virtually ubiquitous in the average American diet. Wheat often is used as an extender in processed foods and is present in many brands of commercially available ice cream, salad dressings, and canned foods; some brands of instant coffee, ketchup, and mustard; and most candy bars. Thus, it is important for persons with CD to read food labels carefully.