Making Sense of Gluten Sensitivity And Celiac Disease

celiacs disease and gluten sensitivity

The Food-Related Allergies in Our Lives

Allergens of all kinds surround us. The consequences range from the mildly irritating to the downright life-threatening.

Sooner or later, the afflicted find themselves sensitive to some environmental condition, to textiles, fur and other clothing, to paint, smoke, scents, flowers and food. Food and drink is especially pernicious. The sheer variety is so vast one may unwittingly encounter a new food or beverage to which one turns out to be allergic.

With age, otherwise, degenerative processes set in. A person may develop Gluten Sensitivity or Gluten Intolerance, not readily apparent at first but soon enough progressing to Celiac Disease.

What is Gluten?

Gluten is an abundant protein found in all forms of grains. A variety of authoritative sources stress the fact that there is quite simply no avoiding gluten. It is found in all forms of grain.1

Gluten further segments into two different fractions called prolamines and glutelins. Among the former, gliadin is the protein sub-type which has earned the most attention in the medical literature owing to its link with celiac disease.

The prolamines differ and vary by composition in each grain class. Wheat has gliadin, which contributes 69% of total protein content. For rice, on the other hand, just 5% of total protein consists of orzenin, also a type of prolamine.

Grains and Gluten

The grain staples range from oats to rice, wheat, maize and many more. The seed, or the grain as we know it, has a bran casing which is a starchy endosperm. Gluten is commonly found on the endosperm and contains 90% of the total proteins found in these grains. The endosperm is commonly processed and is used for the production of flour. Thus, flour should be also avoided by the gluten-intolerant people.

Gluten Sensitivity

Gluten sensitivity is defined as the body’s immune reaction towards the protein gluten which is normally found in significant amounts in wheat, barley and rye. Physiological sensitivity has also been noted for other grains such as oats, often mistakenly (or deliberately) labelled “gluten-free”.

According to studies, corn is not an exception either even if it is often recommended as a substitute for most grains when one is sensitive to gluten. The prolamines found in maize/corn are concededly low but nevertheless active enough to produce a reaction with gluten-sensitivity.2 The gluten in corn has inflammatory activity even if it is reported to be harmless. Corn gluten created a similar inflammatory reaction in celiac disease patients with proven hypersensitivity to wheat gluten.3

Recent studies on rice showed the role of this staple in promoting enterocolitis (inflammation of the colon). Rice protein can cause this inflammation even if it has low amounts of prolamine.4

Definitional Differences

Gluten allergy is an immune-mediated response triggered by the gluten protein. Gluten intolerance is essentially the inability of the patient’s body to tolerate gluten and is therefore typical of allergic reactions. This means that the body cannot digest the substance like it should. “Gluten sensitivity” is therefore a mesh of both terms.

Do I Have “Gluten Sensitivity” or “Celiac Disease”?

“Gluten sensitivity” tends to be used interchangeably with “celiac disease” because it is the disease process which most researchers focus on. However, gluten sensitivity is not a disease process and is quite simply the allergic state or inability to tolerate gluten. This state progresses to celiac disease if left untreated or not monitored. The better term for “gluten sensitivity” in this case is “non-celiac gluten sensitivity” or “gluten syndrome”.5

Celiac Disease

Celiac disease itself is one of over 200 clinical conditions or manifestations which reveal themselves depending on the progression of the disease and the individual. Gluten sensitivity is like a hub or the common factor for all these manifestations. It is not in itself a disease but merely a state of being.

Gluten sensitivity is not a disease. It is caused by a genetic predisposition and may only present as a manifestation. Celiac disease is a rare manifestation.

Surgically, intestinal biopsy is the gold standard for diagnosing celiac disease. However, biopsy is not really that accurate since there is a margin of error. The tissue samples taken may not be representative.6

Intestinal biopsy requires taking tissue samples from random portions of the patient’s intestine to check for the classical appearance of inflammation within the intestinal mucosa. Even if the patient is cleared for any intestinal inflammation, there is no assurance that non-sampled areas of the intestine are not damaged. No biopsy ever takes samples from the entire intestine as that would be illogical and damaging to the patient’s health.

At present, the gold standard in identifying the disease is through antibody blood testing. HLA-DQ, along with confirmation of the patient’s symptoms, is the highly-recommended diagnostic pathway for establishing gluten sensitivity.

The relevant symptoms are usually systemic. Some who truly have celiac disease may have joint pains instead of intestinal manifestations, the expected ones of extreme weight loss, diarrhea, abdominal pain, bloating and vomiting. Gluten can idiosyncratically affect different organ systems, depending on the individual. Conceptually, therefore, celiac disease originating from gluten sensitivity can affect any tissue or organ system in the body.

While extra-intestinal manifestations are not rare, they should not be the sole basis for identifying the disease process. It is important to note some of these conditions are caused by the systemic involvement in the disease. Not all gluten sensitive patients will present with intestinal symptoms.

Immune Reactions To Gluten

The symptoms of the patient may present themselves within 30-60 minutes of eating meals with gluten but the reaction may also be delayed by from several days to months. Acute immune reaction is due to IgE, which is the substance that the body immediately releases upon intake of the allergen (gluten). This reaction could lead to evincing hives (itching, burning and swelling of the patient’s skin), bronchitis (inflammation of the airways), asthma, coughing, sneezing, diarrhea and/or vomiting.

Delayed Immune Reaction works in 3 different ways to create a chemical inflammation which then leads to tissue damage. This delayed type of hypersensitivity is mediated by IgG.

To test the patient, it is important to monitor the patient’s IgE and IgG. The skin prick test can be used to identify IgE which is sensitive to gluten. This is done by injecting a diluted amount of gluten intradermally. A positive skin reaction confirms the presence of acute hypersensitivity to gluten. IgG specific for gluten can be tested through blood samples and can confirm Delayed Hypersensitivity to Gluten.7

In addition to this, it is important to test for T-cell, IgA, IgM and immune complexes to help identify the Delayed Hypersensitivity Reaction.8

Gluten intolerance means that the patient is unable to tolerate the presence of gluten but the condition does not involve the patient’s immune system. The main tissues involved are the intestinal cells; the condition then leads to Gut Dysbiosis. Since food is poorly digested, the resultant stasis leads to an exponential increase in bacterial flora and by-products.

The increase in bacterial flora leads to an increase in intestinal damage, which creates holes in the intestinal lining. This leads to an increase in allergies as time passes by. The food stasis and lack of digestion continues and it escapes through the gaps in the lining of the intestine. Within the lining are lymph tissues which respond to the food and stimulates an immune reaction which aggravates the condition. The damage which the sensitivity and intolerance creates leads to the disease process at a later time.

Medical Conditions Related to Gluten Sensitivity and Intolerance

Gluten sensitivity is linked to other conditions. However, it is not the sole cause of the medical conditions covered by this section. It is important to do a thorough workup of the patient and in cases where the underlying cause is not readily apparent, gluten intolerance and sensitivity should be considered.

Medical conditions related to the disease process and gluten intolerance emerge from lack of digestion and absorption of essential food groups, micro and macronutrients, such as calcium, vitamin D and thiamine. Some of the medical conditions include angina pectoris (chest pain), anorexia, anxiety attacks, apthous ulcers (oral sores), aortic vasculitis, vitamin-related anemia, ADHD, Addison’s disease, atherosclerosis, Dermatitis Herpateformis (which is the most common skin manifestation of this disease), cachexia, bone pain, asthma, cardiomegally, cataracts, chorea, dysmenorea, diabetes mellitus type I and many more.

Gluten could trigger epileptic seizures as well. This is because some epileptic seizures can be triggered by allergens to which the patient is highly sensitive. Vitiligo could also arise, which is the skin’s immune reaction involving loss of skin pigment.

The malabsorption the patient suffers lead to a decrease in vitamins and minerals absorbed. An example of this is vitamin D. It is important for calcium absorption and bone health. Vitamin D is important in maintaining muscle strength and balance. Since the vitamin has immune-modulating effects, a deficiency may contribute to the worsening of the immune disease.

Thiamine deficiency (vitamin B1) can lead to memory loss, depression, irritability, edema, muscle pain and fatigue.

Show 8 footnotes

  1. Osborne, P. (2011, December 28). Gluten sensitivity, a laymen’s primer. Glutenology. Podcast retrieved from https://www.youtube.com/watch?v=cv5RwxYW8yA.
  2. Sandhu, J.S. & Fraser, D.R. (1983). Effect of dietary cereals on intestinal permeability in experimental enteropathy in rats. Gut, 24:825-830 doi:10.1136/gut.24.9.825.
  3. Kristjánsson,G., Högman, M. Venge, P. & Hällgren, R. (2005). Gut mucosal granulocyte activation precedes nitric oxide production: Studies in coeliac patients challenged with gluten and corn. Gut, 54 (6): 769–774.
  4. Mehr, S., Kakakios, A., Frith, K., et al. (2009). Food protein induced enterocolitis syndrome: 16 year experience. Pediatrics, 123 (3) 459-464.
  5. Ford, R. (2014, May 20). Dr. Rodney Ford: Zero Gluten, Worldwide. About. Retrieved from http://celiacdisease.about.com/od/glutenintolerance/a/Dr-Rodney-Ford-Interview.htm
  6. Osborne, op. cit.
  7. Caruso, L. B., & Silliman, R. A. (2008). Geriatric medicine. In A. S. Fauci, E. Braunwald, D. L. Kasper, S. L. Hauser, D. L. Longo, J. L. Jameson, & J. Loscalzo (eds.), Harrison’s principles of internal medicine (17th ed.). Retrieved from http://0-www.accessmedicine.com.oswald.clark.edu/content.aspx?aID=2860282.
  8. Osborne, op. cit.