Many people experience a range of symptoms, and some no symptoms at all. Common symptoms include abdominal pain, dermatitis herpetiformis (Coeliac rash or gluten rash - not from contact with gluten, but from ingestion), infertility, numbness in legs, anemia, diarrhoea, joint pain, osteopenia, bloating, mottled teeth, pale skin, sores in the mouth, osteoporosis, delayed growth, fatigue migraines, weight loss, depression, gas, and nausea (1-5).
Having an initial blood test to diagnosis Coeliac disease is essential; a simple antibody blood test will indicate elevated inflammatory markers such as the presence of anti-tissue transglutaminase antibodies (tTGA) or anti-endomysium antibodies (EMA) (1-3). Usually an endoscopy, and jejunal biopsy will be performed to confirm diagnosis (1 – 3). To prepare for the blood tests, gluten should be consumed to generate some reaction, otherwise a false negative could be produced and a correct diagnosis not made. In families with confirmed Coeliac disease, a genetic test maybe performed (as first degree relatives have high prevalence of about 10%), this only confirms you have the genes, but not necessarily the disease (1,6). It is usually developed after a stressful event, environmental factors or changes in other genes (6). About 30% of the general population is estimated to that have the specific gene variants, but only 3% of individuals will go on to develop celiac disease (6).
Non-Coeliac gluten sensitivity is a term given to individuals who have Coeliac-like symptoms but whose blood tests are negative. They may go on to have a biopsy, which is likely to also be negative. Following a low FODMAP diet, eliminating and then reintroducing foods, may indicate other foods that you are sensitive to, and it may also indicate foods you can tolerate that you thought you couldn’t (5). Non-Coeliac gluten sensitivity is not accompanied by “the enteropathy, elevations in tissue-transglutaminase, endomysium or gliadin antibodies, and increased mucosal permeability that are characteristic of Coeliac disease” (7). Currently, the only way to confirm gluten sensitivity is through a process of elimination – by testing negative for Coeliac disease and wheat allergy, and then eliminating gluten under the supervision of a physician or registered dietitian skilled in Coeliac disease. Gluten intolerance is an old outdated term and should not be used; gluten-related disorders should be used instead (6).
Symptoms of an allergy to wheat can include itching, hives, or anaphylaxis, a life-threatening reaction. Usually after a positive blood test for IgE food allergies, a further RAST blood assay may be done, and then a skin prick test performed with the suspected allergen. These tests alone or together will rule out a food allergy, and an oral food challenge under medical supervision will confirm diagnosis (8). The treatment for wheat allergy is to remove all forms of wheat from the diet. A person with a wheat allergy must avoid eating any form of wheat, but does not have trouble tolerating gluten from non-wheat sources (9). It is possible for a person to be both allergic to wheat and have Coeliac Disease or Non-Coeliac gluten sensitivity (8).
Adherence to a life-long gluten free diet is the only way to prevent damage to the intestine, as even tiny amounts of gluten can cause damage to the villi and prevent sufferers from absorbing nutrients into the blood stream (1 – 3). See a Registered Dietitian specializing in Coeliac disease to guide you with eating a nutritionally balanced gluten free diet. At present there are no pharmaceutical treatments for Coeliac disease, although a vaccine using immunotherapy (using the body’s own immune system to treat disease), nanoparticle treatments, cereal genomics, and some other novel therapies are in trial phases and may become treatments in the future (1, 8). Managing Coeliac involves an expert team approach with skilled a physician and dietitian, regular education about Coeliac disease and the gluten-free diet, identifying credible support and advocacy groups, potentially discussing the need for a psychologist who can help with acceptance and coping, educating relatives (including asking for their support and for them to be tested) and regular follow-up care and testing.
We have a fantastic course on IBS and FODMAPs from Chloe McLeod that you can watch, and a Coeliac disease presentation to be released in the next few months by expert Dietitian Kim Hogg-Faulkner.
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1. Ludvigsson, J. F., Bai, J. C., Biagi, F., Card, T. R., Ciacci, C., Ciclitira, P. J., ... & Kaukinen, K. (2014). Diagnosis and management of adult Coeliac disease: guidelines from the British Society of Gastroenterology. Gut, gutjnl-2013.
2. Husby, S., Koletzko, S., Korponay-Szabo, I. R., Mearin, M. L., Phillips, A., Shamir, R., ... & Lelgeman, M. (2012). European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of Coeliac disease. Journal of pediatric gastroenterology and nutrition, 54(1), 136-160.
3. Rubio-Tapia, A., Hill, I. D., Kelly, C. P., Calderwood, A. H., & Murray, J. A. (2013). ACG clinical guidelines: diagnosis and management of Coeliac disease. The American journal of gastroenterology, 108(5), 656.
4. Reilly, N. R., & Green, P. H. (2012, July). Epidemiology and clinical presentations of Coeliac disease. In Seminars in immunopathology (Vol. 34, No. 4, pp. 473-478). Springer-Verlag.
5. Lewis, N. R., & Scott, B. B. (2006). Systematic review: the use of serology to exclude or diagnose Coeliac disease (a comparison of the endomysial and tissue transglutaminase antibody tests). Alimentary pharmacology & therapeutics, 24(1), 47-54.
6. https://ghr.nlm.nih.gov/condition/celiac-disease#genes
7. Sapone, A., Lammers, K. M., Casolaro, V., Cammarota, M., Giuliano, M. T., De Rosa, M., ... & Esposito, P. (2011). Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: Coeliac disease and gluten sensitivity. BMC medicine, 9(1), 23.
8. Majamaa, H., Moisio, P., Majamaa, H., Turjanmaa, K., & Holm, K. (1999). Wheat allergy: diagnostic accuracy of skin prick and patch tests and specific IgE. Allergy, 54(8), 851-856.
