- 1 Celiac Disease:
- 2 Past History:
- 3 On Examination :
- 4 General Physical Examination :
- 5 Systemic Examination :
- 6 Investigations Advised:
- 7 Definition Of Health Inequity:
- 8 DISCUSSION :
- 9 Signs and Symptoms of celiac disease
- 10 Signs and Symptoms of Celiac Disease in Children
- 11 Older children may experience:
- 12 Dermatitis herpetiformis
- 13 Causes of Celiac Disease
- 14 Risk factors for Celiac Disease
Celiac Disease is an immune-mediated systemic disorder, that is elicited by gluten (present in foods) and related prolamines in genetically susceptible individuals.
In the majority of the developing countries, celiac disease is still a threat to patients as there is still little awareness about this condition.
In this article, I will discuss signs and symptoms of celiac disease with the risk factors. Along with this, I will discuss in detail about what complications and problems can arise if there is no knowledge about Celiac Disease in general public and especially healthcare related individuals.
Eyes Don’t See, What Brain Doesn,t Know
Health Inequity. A Case to learn
By Dr. Muhammad Farooq Haider
YK was 8 years old boy living 60 km away from the city of Multan. He was brought to our hospital by his uncle because he was concerned about his growth.
According to him he was not gaining weight and his height was also short compared to children of his age group, His uncle was only one in the family who was educated and brought him to the city with him for examination at our hospital. YK lived in a small town where there is just one basic health unit and no child specialist or even qualified doctor, with just one dispenser. His family visited that health center and dispenser there advised them to give him lots of food so he may get healthy and he should have food that is full of Nutrition. He advised them to give YK bread and milk and everything he can eat.
YK was youngest of all in the family and he had one elder sister who was 18 years old and was having normal height and weight. He had no vaccination record.
YK uncle gave the history of GI disturbance, diarrhea and bloating at the start of weaning at age of 7 months and he remained admitted for 1 day at the local dispenser clinic at his area and was treated as a case of gastroenteritis.
After that admission patient failed to achieve normal growth and YK had multiple visits at his local clinic for vomiting and diarrhea.
On Examination :
Temperature : 37.7 Celsius , HR : 96/min R R : 30/min Height : 110cm wt : 16kg
General Physical Examination :
YK looked unwell, irritable, pale with no obvious dysmorphism, pallor and clubbing were observed. No rash is seen.
Systemic Examination :
Failure to thrive, abdomen distended with visible veins, muscular wasting prominent at buttocks.
YK was advised Complete blood picture, ESR, Routine stool examination for ova and cyst. Anti-tissue transglutaminase IgA and IGG antibody were sent and in addition to total IgA in serum to exclude IgA deficiency in serum.
Labs came strongly positive for Celiac disease. YK and his uncle were counseled about the disease and guided about the gluten-free diet. They were surprised by this condition as they had had no idea about this condition. They were giving him bread three times a day as local dispenser advised them which was worsening the condition.
YK was advised multivitamins and oral Iron therapy for anemia and oral vitamin d 3 therapy and guided in detail about the role of gluten-free diet.
YK came back after a month. He was on the strict gluten-free diet and was regularly taking medicines. His uncle commented that his mode had improved and he had a good catch up growth, and now he looked improved and different child. Read here about Foods Rich in Calcium.
Definition Of Health Inequity:
American Academy of Pediatrics defines it as a combination of four elements:
1. children right
2. Social justice
3. Human capital investment
4. Health Equity Ethics
Above mentioned components are essential for health equity.
Health inequity arises from health inequalities. Inequity is avoidable by equalities in the health system.
Health inequity refers to unfair, avoidable differences arising from poor governance, corruption or cultural exclusions while inequality refers to the uneven distribution of health resources as a result of genetic or other factors. Read here about Causes of Obesity.
Celiac Disease is an immune-mediated systemic disorder, elicited by gluten and related prolamines in genetically susceptible individuals.
YK uncle had no knowledge of celiac disease and was very poor and their local dispenser also had no idea about this condition. Celiac disease complications can easily be avoided by using the gluten-free diet.
The patient may not have developed complications if diagnosed and treated at early stage.
YK local hospital dispenser kept on treating him as a case of gastroenteritis and had poor knowledge of diseases. YK family had no funds for him to travel to the city so he had to depend on local dispenser till his uncle brought him to the city.
There is a strong need for campaigns to teach and guide parents about this condition and guide them how to avoid complications associated with this.
Educating and teaching school teachers can play a vital role as they can guide children and parents.
As they say “Eyes Don’t See, What Brain Doesn’t Know”
If local dispenser had the idea of this condition only then he could have guided YK family.
Celiac profile just costs around 20 $ to 25 $ in this region which is not costly but awareness about this disease is important and the patient can live the healthy life with no complications.
Signs and Symptoms of celiac disease
In children, malabsorption can affect growth and development that may result in stunted growth, in addition to the symptoms seen in adults.
The signs and symptoms of celiac disease may vary and are different in different age groups. The most common signs for adults include diarrhea, fatigue, and loss of weight. Adults may also experience bloating and gas, abdominal pain, nausea, constipation, and vomiting in addition to the symptoms already mentioned..
However, you must know that more than half of adults with celiac disease show signs and symptoms that may not be related to the digestive system, these may include:
- Anemia, usually resulting from iron deficiency
- Loss of bone density (osteoporosis) or softening of bone (osteomalacia)
- Itchy, blistery skin rash (dermatitis herpetiformis)
- Damage to dental enamel
- Mouth ulcers
- Headaches and fatigue
- Nervous system injury, including numbness and tingling in the feet and hands, possible problems with balance, and cognitive impairment
- Joint pain
- Reduced functioning of the spleen (hyposplenism)
- Acid reflux and heartburn
Signs and Symptoms of Celiac Disease in Children
In children under 2 years old, typical signs and symptoms of celiac disease may include following:
- Chronic diarrhea
- Swollen belly
- Failure to thrive
- Poor appetite
- Muscle wasting
Older children may experience:
- Weight loss
- Short Stature
- Delayed puberty
- Neurological symptoms, including attention-deficit/hyperactivity disorder (ADHD), learning disabilities, headaches, lack of muscle coordination and seizures.
Dermatitis herpetiformis is a condition that starts with an itchy, blistering skin disease that stems from intestinal gluten intolerance. This rash normally occurs on the elbows, knees, torso, scalp, and skin around the buttocks.
Dermatitis herpetiformis is normally associated with changes to the lining of the small intestine identical to those of the celiac disease, but the disease may not produce noticeable digestive signs and symptoms.
Doctors often treat dermatitis herpetiformis with a gluten-free diet or medication, or both, to control the rash and it normally cures with the dietary adjustments and medications.
Causes of Celiac Disease
Celiac disease happens because of an interaction between genes, eating foods with gluten and few environmental factors, but the main and precise cause is unknown. It is also believed that Infant feeding practices, gastrointestinal infections, and gut bacteria might contribute to the development of celiac disease.
Often Celiac disease is initiated — or starts for the very first time — post-surgery, during or after pregnancy, childbirth, acute viral infection or severe emotional stress. There are a couple of researchers that indicate these factors.
When the body’s immune system responds to gluten in the food, the reaction of the body damages the tiny, hair-like projections that line the small intestine. These Villi also absorb vitamins, minerals and other nutrients from the food you eat. If somehow villi are damaged, you can’t get enough nutrients, no matter how much you eat because nutrients are absorbed by the villi.
Few gene variations appear to enhance the risk of developing Celiac disease. However even having those gene variants don’t guarantee that you will get celiac disease, this shows that there are few other factors that must be involved in the development of the disease.
Risk factors for Celiac Disease
Anyone can be affected by Celiac disease. But there are few risk factors which may increase the chances of developing celiac disease.
- Family member that is suffering from celiac disease or skin condition that is dermatitis herpetiformis
- Type 1 diabetes
- Down syndrome or Turner syndrome
- Microscopic colitis (lymphocytic or collagenous colitis)
- Addison’s disease
- Rheumatoid arthritis
- Autoimmune thyroid disease
Complications of Celiac Disease
If celiac disease is treated and essential dietary adjustments are not made then it can cause following conditions:
- When small intestines are damaged that means you will not be able to absorb essential nutrients from your food. Even if it absorbs the percentage is in fractions of what small intestines can absorb. This will lead to malnutrition. Malnutrition will lead to anemia and progressive weight loss. Children if diagnosed with celiac disease, must be treated otherwise they can show signs of slow growth and short stature
- Loss of calcium and decrease bone density. Since there will be loss of calcium and vitamin D as they can not be absorbed properly by the human body. This will lead to a softening of the bone (osteomalacia or rickets) in children and a loss of bone density (osteoporosis) in adults. All precautions must be taken to avoid such complications.
- Infertility and miscarriage.Since there is malabsorption of calcium and vitamin D and this can contribute significantly to reproductive issues and even infertility and miscarriage.
- Lactose intolerance. If the small intestine is damaged, it can lead to abdominal pain and diarrhea after eating dairy products that contain lactose. Only after healing of intestines, you will be able to use and tolerate dairy products. But you must remember this will continue with individuals with celiac disease.
- This is a serious complication of celiac disease. Individuals with celiac disease should have dietary adjustments and if they don’t maintain a gluten-free diet, they ll at risk of developing several different forms of cancer, including intestinal lymphoma and small bowel cancer.
- Neurological problems. Individuals with celiac disease may develop neurological problems such as seizures or peripheral neuropathy (disease of the nerves that lead to the hands and feet). However, there is less percentage of people with such problems.
Children suffering, celiac disease can also lead to failure to thrive, delayed puberty, weight loss, irritability and dental enamel defects, anemia, arthritis, and epilepsy.
The rate of celiac disease in Western countries is estimated at about 1 percent of the population. Caucasians have the higher percentage of Celiac disease.; however, it is now being diagnosed among many ethnic groups and is being found globally. In Asian countries, many new cases are being reported on the daily basis. In Pakistan, many organizations have started working for awareness among general public about the celiac disease and this article is just one example.
There’s no cure for celiac disease, once diagnosed, you can never cure it — but for most people, following a strict gluten-free diet can help manage symptoms and promote intestinal healing.
Our doctors at QMC MULTAN have started free OPD services in remote regions and also we have started weekly lectures by our medical team about avoidable conditions in rural areas and focus on parents education and counseling.
1. Nelson Textbook of Pediatrics 20th Ed chapter 338.2 Celiac Disease
2. Inequity and Inequality In Health By Global Health Europe 24th Aug 2009
3. Health Equity and Children,s Rights Pediatrics In review, April 2010, volume 125 / issue 4
Dr. Muhammad Farooq Haider
Head of Pediatrics, QMC Multan.
Principal QIMS, Multan.
Dr. M Yousaf
Registrar Pediatrics, QMC Multan.