A Gastroenterologist’s Personal Journey Down the Gluten Rabbit Hole

Celiac disease and non-Celiac Gluten Sensitivity (NCGS)

Gluten intolerance resulting in symptoms and illness similar to celiac disease (CD) without meeting diagnostic criteria for CD is a new concept. This concept of non-celiac gluten sensitivity (NCGS) or gluten related disease (GRD) may be a new paradigm that is hard for some people to swallow, especially when I suggest that it affects as much as 10% to 30% of the population.

Wheat gluten as a cause of illness

Gluten ingestion is an avoidable, treatable, and reversible cause of illness in many people. It is contributing to the rising epidemic of autoimmune diseases. Many resist these concepts finding them either unbelievable, unacceptable or both. I believe that their rejection is neither rational nor helpful. It may be reasonable to reject them for cultural or financial reasons though I don’t believe they can legitimately be rejected based on scientific grounds or experience.

Celiac disease not rare and is often missed as a diagnosis

Celiac disease is not rare. CD affects 1 in 100 people in the world. Yet the diagnosis of CD is still frequently missed and/or delayed. It is a common disease that is often undiagnosed or misdiagnosed. It may even be the most common autoimmune disorder. Though the risk is largely genetic, it is preventable by simply avoiding gluten. Autoimmune diseases associated with CD may also be preventable by avoiding gluten.

What doctors remember from medical school about Celiac disease

When I was in medical school over twenty-five years ago, I was taught that CD was rare. In residency we were shown photos of short, emaciated children with skinny limbs and pot-bellies. We were told that their medical history included symptoms of profuse, watery, floating, foul-smelling diarrhea, and iron deficiency anemia. The picture and story was burned into the hard drive of our brains, not necessarily because anyone believed we would see someone with CD in our practice, but because CD was considered rare and odd enough that it was a favorite board examination question. That image and story remains in the mind of most physicians, preventing them from seeing CD in a much broader light.

Blood tests for Celiac disease become available

When I entered subspecialty training in gastroenterology, 13 years ago, specific blood tests for CD were available but still new. We were beginning to order the blood test when classic symptoms of CD were seen without an identifiable cause, or if we happened to sample the small intestine during endoscopy and classic Sprue changes were seen in the intestinal biopsy. CD was still considered somewhat rare. We did not routinely biopsy the small intestine to screen for CD, and genetic tests were not yet available.

Celiac disease is common but gluten sensitivity more common

It wasn’t until Dr. Fasano, a pediatric gastroenterologist from Italy, published a landmark article reporting Celiac disease affected 1/133 people in the U.S that American doctors began thinking more about it. Only recently has it been accepted that family members of people with CD, those with digestive symptoms, osteoporosis, anemia, and certain neurological, skin or autoimmune disorders constitute high risk groups for celiac disease. They have an even higher risk of between 2% to 5%, though most physicians are unaware of these statistics. Every week, using the strict diagnostic criteria, I confirm 2-3 new of CD. I also see 5-10 established CD patients. However, for every identified CD patient there are 3-10 who have clinical histories consistent with CD, but who fail to meet the diagnostic criteria. Yet they respond to a GFD. Many have suggestive blood test results, biopsies and or gene patterns but some do not.

Genetic link to Celiac disease and gluten sensitivity

More than 90% of people proven to have CD carry one or both of two white blood cell protein patterns or human leukocyte antigen (HLA) patterns HLA DQ2 and/or DQ8. However, so do 35-45% of the general U.S. population, especially those of Northern European ancestry. Yet CD is present in only 1% of the same population. DQ2 or DQ8 are considered by some experts to be necessary though not sufficient to develop CD. However, CD without those two genes has been reported. Read the rest of this entry »

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Gastroenterology – A Gut Reaction

The digestive system is a complex system that involves the process of taking food into the body, and turning it into a digestible form that can then be assimilated into the body to supply the necessary nutrients for functionality and good health.

Food is taken into the body through the mouth where it’s broken down by a combination of proper chewing and natural body fluids produced in the mouth. The broken down food is then passed through the esophagus into the stomach where it is combined with digestive enzymes that further break down the matter into digestible form. Then nutrients from the food are absorbed into the body through the small intestine. Stretched out, the average small intestine is about 22 feet long, and the large intestine is about 5 feet long. That’s a lot of geography. The residue, called fecal matter, is then passed through the small intestine into the large intestine to the rectum where it is eliminated by the body as waste or feces. Constipation can occur if there isn’t enough liquid intake to moisten the feces as the passes through the large intestine.

This process involves other vital organs such the pancreas, which is located beneath the stomach where it connects to the small intestine through the duodenum. The pancreas produces insulin and glucomen; digestive enzymes and hormones that help breakdown carbohydrates, proteins, and fats. The liver, a major player in metabolism, aids in the breakdown of small and complex molecules. Most commonly, the liver is known to detoxify the body when alcohol is introduced into the body but, It also produces bile, which emulsifies fats and neutralizes acids in partly digested food. The gall bladder stores bile secretions from the liver. Read the rest of this entry »

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