Celiac disease is an autoimmune disorder that affects the gastrointestinal tract and is thought to be triggered by dietary gluten in affected individuals. The disease is characterized by chronic inflammation of the small intestinal mucosa, which leads to atrophy of the small intestinal villi and subsequent malabsorption (Pelkowski and Viera 2014). Celiac disease affects approximately 1% of the U.S. population and typically occurs in persons of European ancestry as well as persons of Middle Eastern, Indian, South American, and North African descent. It is two to three times more common in women. Celiac disease is not a food allergy.
Signs and Symptoms
Typical presentation includes chronic diarrhea with cramping and gas pains. Patients often have weight loss, or in the adolescent, delayed onset of growth or puberty. A history of nervousness and/or depression is often present, as is a family history of autoimmune disease. Other complaints may include bone or joint pain, migraines, weakness, fatigue, and anemia (Volta et al. 2015; Vivas et al. 2015; Byrne and Feighery 2015; Mancini, Trojian, and Mancini 2011). Physical examination is often normal, but the patient may present with abdominal distension or dermatitis herpetiformis.
Referral and Diagnostic Tests
Lab tests are performed for differentiating celiac disease and to rule out more common diseases. These include a basic metabolic panel, CBC (iron deficiency), TSH (thyroid disease), vitamin D level, and allergy testing. If celiac disease is suspected from history and physical exam, the initial serologic test is a tissue transglutaminase (tTG) antibody level. This antibody is found in every tissue in the body and acts to join proteins together. In people with celiac disease, tTG activates specific immune cells and triggers the inflammatory response that leads to atrophy of the villi in the small intestine (Mancini, Trojian, and Mancini 2011). The diagnosis is often confirmed with repeat blood tests after 4 wk on a gluten-free diet. Endoscopy with biopsies of the duodenal mucosa may be necessary to confirm the diagnosis. Celiac disease should be differentiated from GERD, pancreatic insufficiency, Crohn’s disease, or other inflammatory bowel diseases.
Treatment and Return to Participation
The general treatment is to remove gluten from the diet. The patient can substitute rice, corn, and soybean flour for products that contain gluten. Periodic blood tests are performed to measure the levels of the antibodies. The levels will normalize with gluten abstinence. Abstinence will be required for life because the immune response to gluten will recur if gluten is consumed again. Usually no medications are prescribed for celiac disease, but athletes may benefit from iron, vitamin, and calcium supplements. The most difficult aspect for the athlete with celiac disease is the dietary restrictions while traveling with the team or with set team meals. The athletic trainer may need to check on the gluten-free status of many of the standard gluten-containing products provided by the athletic department, such as energy drinks or meal replacement bars (Mancini, Trojian, and Mancini 2011).
Gluten Sensitivity and Intolerance
Over the past 10 yr, the number of people choosing a gluten-free diet (GFD) is much higher than the projected number of celiac disease patients (Lis et al. 2015). This has fueled a global market of gluten-free products and highlights several conditions related to the ingestion of gluten. There are three main forms of gluten reactions: allergic, autoimmune (celiac disease), and immune-mediated conditions (gluten sensitivity) (Sapone et al. 2012). Wheat allergy is an adverse reaction to wheat proteins with onset in minutes to hours after gluten ingestion. It may affect the skin, GI tract, or respiratory tract. Celiac disease or other autoimmune gluten disorders generally present months to years after gluten exposure. There is a third condition where some people experience distress from eating gluten-containing products and show improvement with a GFD. It is distinct from celiac disease and wheat allergies (Vivas et al. 2015). Gluten sensitivity cannot be distinguished clinically; serology tests need to be conducted. Patients with GI discomfort or distress following gluten ingestion should be referred for a follow-up blood test and immune-allergy tests.