The prevalence of celiac disease in the general population was believed to be 1 in 300, but recent evidence suggests that there are more undiagnosed than diagnosed cases. Our assumption is that if you look at symptomatic populations with gastrointestinal symptoms or autoimmune disease, then incidence will be much higher. 

The classic presentation of Celiac Disease is chronic diarrhea, with abdominal bloating, sometimes pain, weight loss, iron deficiency and other evidence of nutrient malabsorption.  The disease is immune mediated. Proteins in the cereal grains are responsible for the disease.  The suspect group of proteins are called  "Gluten"  Since a strict gluten-free diet is protective against the complications of adult celiac disease, it is important that the undiagnosed forms of celiac disease or "wheat allergy" are diagnosed and treated.   Screening tests, such as anti-gliadin and anti-endomysium antibody estimation can be used in groups considered to be at risk of celiac disease. These include first-degree relatives of celiac patients and patients with irritable bowel syndrome, arthritis, diabetes mellitus, iron-deficiency anemia, epilepsy with cerebral calcification, recurrent aphthous stomatitis and dental enamel hypoplasia.

Ciacci et al ( Scand J Gastroenterol, 1995 Nov, 30:11, 1077-81) suggested that Celiac disease may present in various forms. Their study showed that the disease is more frequent in women, more severe and more rapid. They stated: "The data also suggest the need to look for celiac disease in patients with unexplained hypochromic anemia. Except for asthenia, all signs and symptoms were more frequent in women than in men. Hypochromic anemia was the most commonest finding in women and was 40% more frequent in women than in men. Dyspepsia was twice as frequent in women as in men genital disorders were reported by 44% of women and by no men. Recent weight loss or low body mass index was the commonest finding in men. About 60% of men and women reported diarrhea; among patients without diarrhea, the prevalence of hypochromic anemia differed between sexes, occurring in about 80% of women."

Medical textbooks dogmatically state that an intestinal biopsy must be taken and must show typical changes before the diagnosis is made. The biopsy allows a pathologist to examine microscopically the surface of the small intestine. The surface of the small intestine is covered by a dense mat of projecting nipples called villi which shed cells containing digestive enzymes, and absorb food molecules. In the typical case, jejunal biopsy reveals villous atrophy, inflammatory infiltrate of the lamina propria, and degeneration of the surface epithelium.  Celiac disease, as defined by the biopsy result, probably represents a specific endpoint for gluten reactions; one of many possible patterns of wheat allergy. In long-standing celiac disease, one expects the villi to be blunted and the surface to be smoothed out. While the biopsy is a useful procedure it has several drawbacks;

• It is a procedure with a small incidence of complication, especially bowel perforation.
• It is a small sample and may miss patchy or irregular bowel changes.
• Significant protein intolerance, and increased bowel premeability  may exist despite normal appearance of the bowel lining under the microscope.
• Patients in remission or with intermittent symptoms may have normal biopsy results but remain exquisitely sensitive to gluten

The most significant test of gluten intolerance is remission of symptoms when grains are eliminated for a trial period of 3-6 weeks. I have often reviewed the history of patients with chronic diarrhea, and associated abnormalities, who have been "thoroughly investigated" in an academic center and left untreated because their biopsy result was normal. Physicians, who make therapeutic decisions solely on the basis of biopsy results are being dogmatic, not scientific, and certainly not serving the best interests of their patients who simply want to be better. Investigations which do not lead to effective therapy are of no value to patients.

Diagnosis of gluten-sensitivity in all disorders may be facilitated in the near future by better immunological laboratory tests, including measurement of circulating serum antibodies directed against these proteins, and of circulating immune complexes which contain food antigens.

Too many patients have been dismissed without proper Diet Revision Therapy. When a biopsy is reported as "normal", they are sometimes told, "You do not have celiac disease; eat anything you like." This diagnostic rigidity manifests the classic error of "treating the lab result" and not the patient. Patients with chronic diarrhea and other symptoms suggestive of celiac disease often have milk and wheat allergy and benefit from Diet Revision Therapy, regardless of the biopsy result.

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