postheadericon Coeliac disease (coeliac sprue or gluten allergy)


What is coeliac disease?

Term watch

Coeliac disease is also known as gluten enteropathy or coeliac sprue.
Coeliac disease is a lifelong autoimmune condition, which is a multi-system disorder diagnosed by endoscopy with biopsy, of the small intestine (bowel).
Gluten is predominantly a mixture of two proteins, gliadin and glutenin. It is found in wheat, barley and rye. When combined with water gluten becomes sticky and forms the familiar texture of dough.
In coeliac disease, gluten causes the immune system to produce antibodies that attack the delicate lining of the bowel, which is responsible for absorbing nutrients and vitamins from food.
Coeliac disease can be diagnosed at any age and can be diagnosed in babies after weaning, when cereals containing gluten are first introduced into the diet. However, the most common age of diagnosis is currently between 40 and 60 years old.
The symptoms can be subtle, and you may feel unwell for some time for no reason before the diagnosis is made.
If left untreated, coeliac disease can lead to anaemia, low bone density, osteoporosis and, rarely, some forms of gut cancer.
Avoiding all food that contains gluten generally results in the improvement, or even disappearance, of damage to the bowel lining. However, the damage will start again if gluten is re-introduced into the diet.

How does gluten damage the bowel?

NetDoctor


Healthy villi of the small intestine (as seen under the microscope).
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Damaged villi of the small intestine.
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Villi completely destroyed by the immune system. All pictures courtesy of Prof PJ Ciclitira.
The small bowel contains villi, which are tiny finger-like projections that are only visible under a microscope.
They provide a large surface area over which we absorb nutrients such as folic acid, iron and calcium.
If you have coeliac disease, a reaction occurs when gluten comes into contact with the lining of the small bowel.
The villi are attacked by the immune system and become inflamed and flattened, as seen in the pictures above.
This results in nutrients from food going down the gut without being absorbed (malabsorption), leading to diarrhoea, vitamin and mineral deficiencies, anaemia and thin bones (osteoporosis).

Who is at risk?

It used to be thought that coeliac disease affected about 1 in 1500 people. More accurate diagnosis through blood tests has shown that the condition affects 1 per cent of people across Europe. Coeliac disease affects all ethnic groups and is common not just in Europe, but also in South Asia, the Middle East, North West and East Africa and South America.
Coeliac disease is more common in women than men.
Coeliac disease is associated with other conditions. People with Type 1 diabetes, and thyroid problemshave an increased chance of developing coeliac disease.
The risk of coeliac disease is increased by a family history of the condition. Coeliac disease occurs in people who are genetically prone to it.
If you have a parent, sibling or child with coeliac disease, you have a 10 per cent chance of also developing it. In identical twins, if one twin has coeliac disease, the chance of the other twin developing coeliac disease is more than 70 per cent.

What are the symptoms?

Term watch

Villi are finger like projections in the gut. They help the body to absorb nutrients from the food we eat.
Coeliac disease has many and varied symptoms, and symptoms in adults may be different to those in children. Symptoms do not appear until gluten-containing foods (bread, cereal) are introduced into the diet.

Childhood symptoms

In childhood: poor appetite, irritability and a failure to thrive are usually the first symptoms.
  • Poor appetite, irritability and a failure to gain weight are usually the first symptoms.

  • Pale, bulky stools that smell nasty.

  • Vomiting and diarrhoea, which can lead to a wrong diagnosis of gastroenteritis.

  • Swollen stomach.

  • Arm and leg muscles may become wasted and thin.

Adult symptoms

In adults symptoms may include:
  • weight loss with pale, offensive diarrhoea

  • constipation

  • abdominal bloating with wind.

However, adults with coeliac disease may not have any of these bowel symptoms. They approach their doctor because of:
  • extreme tiredness

  • anaemia

  • depression

  • bone pain and sometimes even fractures – which are due to thinning of the bones

  • ulcers in the mouth

  • a blistering, itchy skin rash mostly on the elbows and knees, called dermatitis herpetiformis

  • recurrent miscarriages.

More recent research suggests that loss of balance (ataxia) and tingling in the hands and feet (neuropathy) are neurological symptoms found in people with coeliac disease.
The gut symptoms seen in coeliac disease may not always be present in people with the neurological symptoms.

How is coeliac disease diagnosed?

Your GP will ask about your symptoms. Don't feel embarrassed about questions on the frequency and colour of your bowel motions.
Your doctor may also want to know whether you have lost weight or whether you have symptoms of anaemia (tiredness, exhaustion, pallor). The doctor may:
  • examine your abdomen

  • look for a blistering rash on your skin

  • check for mouth ulcers.

Blood tests are then usually requested.
  • Your doctor will check for anaemia, testing the levels of iron, folic acid and calcium in your blood.

  • Another blood test detects antibodies that are often found in coeliac disease. Several antibodies are linked to the condition, but the most specific is anti-endomysial antibody. If this is present in the blood, you are very likely to have coeliac disease.

An endoscopy with biopsy is needed to diagnose coeliac disease. Your doctor should arrange this test at the endoscopy unit at your local hospital.
Children can have endoscopy under general anaesthetic (sedation) and adults may have sedation or a local anaesthetic that numbs the throat with a spray.
It's important that you continue to have a normal diet that contains gluten before having the blood tests and endoscopy for coeliac disease.
The NICE guideline recommends that if the diet has been changed, foods that contain gluten should be eaten in at least one meal everyday for at least six weeks before testing.

Endoscopy and biopsy

  • A thin flexible tube with a tiny camera and clipper at its end is put into your mouth.

  • The camera is guided down the oesophagus (gullet) into the stomach and then the small bowel.

  • The clipper can be used to remove a small piece of the bowel lining during the procedure. This is called a biopsy. You will not feel any discomfort.

  • The whole procedure takes about 10 minutes.

  • The biopsy specimen will be sent to the laboratory to examine the size and shape of the villi. This will confirm diagnosis.

  • It is usual to repeat this test after several months on a gluten-free diet, to check that the lining has recovered.

What else could it be?

Diarrhoea and weight loss can be due to several other causes.
  • A bowel infection caused by parasites called Giardia lamblia and Strongyloides. If your symptoms start after a tropical holiday, one of these infections may be to blame.

  • Overgrowth of bacteria in the small intestine.

  • Lactose (milk) intolerance.

  • Whipple's disease (a rare disease in men that prevents nutrients and fat being absorbed).

  • Intestinal lymphoma (a type of cancer).

What treatment is available?

It's not possible to prevent coeliac disease, but a gluten-free diet can reverse damage to the small intestine. This requires considerable support and information..
After diagnosis your GP should refer you for a consultation with a dietitian, who can give you diet sheets and advice.
It's important that you receive regular follow up from your healthcare team. The general recommendations are to have an annual review appointment.
Another important aspect of treatment is recommending supplements for vitamins and minerals.
If nutrient levels are low, you may need iron tablets, folic acid supplements and calcium. All women should take a folic acid supplement of 400 micrograms a day for three months before conception and for the first three months of pregnancy. This is to protect against neural tube defects such as spina bifida.
If your folic acid levels are low before conception you may need to take a higher dose of five milligrams a day.
It's important to discuss supplements with your GP or local dietitian as they can help to access your individual needs.
Coeliac disease that does not respond to a gluten-free diet may need additional treatment.
In the vast majority of cases, failure of the gut to heal is due to continued gluten in the diet.
If you have been told that your gut has not healed it is important that you see a registered dietitian who can discuss your diet in more detail. Refractory coeliac disease is a term used to describe a condition that does not respond despite following a strict gluten-free diet.
Treatment may include the use of steroids and drugs that 'damp down' the immune system. This is rare.
The gluten-free diet can be nutritionally adequate and balanced. However, the gluten-free diet can be low in fibre and wholegrains, which can cause constipationin some people.
To counteract this, eat plenty of fruit and vegetables.
Tips to increase your fibre intake when following a strict gluten-free diet can be found on the Coeliac UK website. If constipation persists, speak to your local pharmacist, dietitian or GP for further advice.

What is a gluten-free diet?

Things to avoid

The gluten-free diet involves avoiding gluten, the protein found in wheat, rye and barley. Some people are also sensitive to oats.
Gluten is found in the following foods.
  • Bread, pasta and breakfast cereals.

  • Pizza bases.

  • Biscuits, cakes and pastries.

  • Some soy sauces, mustards and mayonnaises.

  • Some tinned soups, sauces, ready meals and some processed foods.

  • Some crisps and similar snacks.

  • Chips should be avoided if cooked in the same oil as battered fish.

  • Beer, lager, stouts and ales are made from grain containing gluten, but other alcoholic drinks such as wine, cider, sherry, spirits and liqueurs can be included in the gluten-free diet.

Most people with coeliac disease can include gluten-free oats in the diet.
Oats are often processed and milled in the same place as wheat. It is therefore important that those including oats in the diet choose gluten-free oats.
Some people can be sensitive to gluten-free oats. This is because oats contain a gluten-like protein called avenin.
If you are thinking about including pure, uncontaminated oats in your gluten-free diet, you should discuss this with your healthcare team (GP, registered dietitian, gastroenterologist) for specific guidance and on-going monitoring.
Current recommendations are that all oats and oat products should be avoided for the first 6 months after diagnosis of coeliac disease to enable you to understand how it feels to be without symptoms.
Prescription medications and medications with a product licence number on the packet are gluten-free.
If a medicine contains wheat starch, this will be indicated on the label and in the patient information leaflet. If concerned you should check with your doctor or pharmacist before taking them.

Foods you can eat

Many foods do not contain gluten, including:
  • all fruit, salads, vegetables

  • potatoes

  • rice and maize

  • nuts

  • pulses and lentils

  • red meat, chicken, fish, eggs and dairy products

  • processed foods such as ready meals and soups which are made without gluten

Coeliac UK produce a food and drink directory, listing foods that can be included in the gluten-free diet.
Gluten-free substitutes are available from most supermarkets and pharmacies. You can also get staples such as gluten-free flour, breads and pasta on prescription from your doctor.
There are excellent books available on gluten-intolerance, including general guides and recipe books.

What complications can coeliac disease cause?

Complications of coeliac disease are rare. They include the following.

Term watch

Autoimmune disease: a disease where the immune system attacks the bodies own cells.
Coeliac disease is an autoimmune disease.
  • Infertility in women. Recurrent miscarriage is sometimes associated with coeliac disease.

  • Severe anaemia in pregnancy because the bowel cannot absorb enough iron and vitamins to keep up with the demands of mother and baby.

  • Intrauterine growth retardation. Babies who are small for their age in the womb are more frequently born to mothers with coeliac disease.

  • Autoimmune diseases (thyroid disease,Type 1 diabetes and some types of liver disease such as primary biliary cirrhosis).

  • Thinning of the bones (osteoporosis).

  • A slightly increased risk of developing bowel cancer, intestinal lymphoma and cancer of the oesophagus.

A gluten-free diet reduces all these complications, as well as treating associated symptoms and conditions such as diarrhoea, mouth ulcers and dermatitis herpetiformis.
Studies have shown that sticking to a gluten-free diet for five years or more reduces the risk of all cancers associated with coeliac disease to that of the general population.

Is there a cure for coeliac disease?

A gluten-free diet should enable the lining of the bowel to return to normal in most people. But damage will return as soon as you start eating gluten again.
This means the disease can be 'cured', but only by avoiding foods that contain gluten. If you do this, you can enjoy a good quality of life without symptoms or long-term complications.

Support groups

Coeliac UK can offer support to help you manage your gluten-free diet. A Helpline is also available on 0845 305 2060 for any questions you have on coeliac disease diagnosis or treatment.

postheadericon Asthma and allergy in winter


Cold and flu viruses


© iStockphoto.com/Sebastian Kaulitzki – asthma allergy winter – influenza virusCold and flu viruses trigger symptoms in 90 per cent of people with asthma. This means people with asthma often find their symptoms are worse in the winter months. Flu is not just a more severe form of a cold – it is a diffe
rent virus that can cause severe complications. Having the flu jab, which is free on the NHS, will boost your body's defences.


Viruses love skin and household surfaces. So make sure you wipe down surfaces regularly and wash your hands after going to the toilet, being outside, coming in contact with food or if someone coughs or sneezes near you.


Cold air and asthma

© NatMag – asthma allergy winter – cold airWhen cold air hits your lungs, it triggers a release of histamine, which causes wheezing in people with asthma. If you
're one of the many whose asthma is triggered by cold air, make sure you wrap up warm when you go outside. Wearing a scarf over your nose and mouth can help, because it will warm up the air as you breathe in. It's also a good idea to have a couple of puffs of your reliever inhaler before you step outside.



Exercise and asthma

© Photodisc – asthma allergy winter – exercise
We all need to keep up our fitness routines in winter, but when cold air triggers asthma it's time for outdoor enthusiasts to switch to the gym. Don't forget to warm up for 10 minutes and take a couple of puffs of your reliever inhaler before you start.





Allergy or cold?

© NetDoctor – asthma allergy winter – morning congestionSneezing, runny nose, itchy eyes, coughing and a tight chest are symptoms we are familiar with from colds. But if morning congestion lasts for weeks or months rather than days, it could be a sign you have allergic rhinitis triggered by mould or mites that linger in dust – and which are at their highest levels in winter. The Royal College of Physicians says three out of four people with year-round congestion may have an allergy.




Don't just rely on medication

© Photodisc – asthma allergy winter – medicationWhile medicines such as antihistamines, inhaled corticosteroids and nasal sprays to thin mucus can ease symptoms, making changes to your environment can make a big difference. Key culprits are cigarette smoke in your house, pets, and old carpets and bedding that trap dust. If symptoms worsen or disrupt your day-to-day life, see your doctor.




House dust mites

© iStockphoto.com/Sebastian Kaulitzki – asthma allergy winter – dust miteDust mites are spider-like creatures that are invisible to the naked eye. They feed on the skin we shed while we sleep and the microscopic mould that grows on mattresses. They are found in all household dust, but mainly in bedding.

It's not the mites that cause the problem, but their droppings – which are the most common indoor trigger for allergies and asthma. Symptoms are worse between October and March because central heating and double glazing trap in allergens and create a warm, humid environment that is the perfect breeding ground for mites.







postheadericon Allergy


What is an allergy?

Allergy or hypersensitivity (type 1 allergy) is an abnormal reaction to protein substances that occur naturally.
Getty - allergyIf an allergic person is exposed to these substances called allergens, the b
ody's immune system gets ready to fight them.
White blood cells (B-lymphocytes) produce an antidote (antibody) against the allergen. The antibody sticks to the surface of the allergy cells. Now the body is ready to fight back the next time it is exposed to the allergen. This process is called sensitisation.
After this change, there is an allergic reaction every time the body is exposed to the allergen.
The allergen sticks to the antibodies on the surface of the allergy cells. This coupling causes the granula (little stores in the allergy cells) to release histamine, which causes the symptoms of allergy.
Depending on the size of the exposure to the allergen and where on the body it happens, there will be an allergic reaction in the form of hay fever, asthma or nettle rash.
The histamine dilates the blood vessels, causes the mucous membranes (lining tissues of the nose and airways) to swell due to the liquid leaking and stimulates the glands in the nose and the respiratory passages to produce mucus (phlegm).
Substances that make the musculature of the respiratory passages contract are released along with the histamine. It becomes difficult to breathe and an asthma attack may follow.
An allergy is very different to an intolerance or sensitivity; there are on the whole no scientific replicable tests for food sensitivities, although it is now possible to test for gluten intolerance (as opposed to gluten allergy or celiac disease) with an NHS blood test available through GP's.

What are allergens?

Allergens are microscopic protein substances that are common and provoke allergic people to produce antidotes (antibodies).
The most common allergy provoking substances are:
  • pollen from weeds, grass, flowers and trees
  • mould and mould fungus
  • house dust mites
  • fur from cats and dogs
  • medicines.

What other things provoke attacks?

Allergic people have very sensitive mucous membranes, which can be irritated by lots of different substances including smoke, pollution, cooking smells, perfume and strong odours.
Children who are often exposed to passive smoking are more at risk of developing allergic reactions.

Does hypersensitivity occur frequently?

The predisposition to hypersensitivity is hereditary.
If one or both parents or close family members suffer from hypersensitivity, it's advisable to talk to a doctor about how to lower the risk of the children developing it.

How can the doctor diagnose hypersensitivity?

It's often enough to tell the doctor when, where and how you get the symptoms. Then they can do an examination that involves skin tests and different blood tests. If asthma is suspected, breathing tests will be performed.

Treatment of allergy

Allergy is a vast subject and some specific types and their treatments are covered in separate factsheets on hay fever and rhinitis, asthma, eczema, pet allergies and food allergies.
Minor allergies can often be treated by over-the-counter remedies, such as antihistamines, examples of which include cetirizine (eg Zirtek allergy tablets) orloratadine (eg Clarityn allergy tablets), which reduce the allergic reaction.
Other remedies are listed below.
  • Nasal products: sodium cromoglicate (eg Rynacrom nasal spray), antihistamines, such as levocabastine (eg Livostin nasal spray), decongestants and corticosteroids, such as beclometasone (eg Beconase nasal spray) – alone or in combination with other products.
  • Eye drops: sodium cromoglicate (eg Opticrom eye drops), nedocromil sodium (eg Rapitil eye drops), antihistamines, such as levocabastine (eg Livostin direct eye drops) – alone or in combination with other products. Corticosteroids are used only in severe cases.
  • Injections of small amounts of the allergy-inducing agent to create tolerance (hyposensitisation) against known allergy-inducing substances. This can prevent the immune system from producing too much histamine. Such treatment has to take place over a long time and requires strict adherence.
  • Rarely, and only in severe cases, intramuscular injections of long-acting steroids can be given, which act for weeks or months to relieve severe symptoms. However, these injections can carry a significant risk of severe side-effects and so are not now given routinely.

postheadericon How to make your home healthy


Home is where the heart is, but it could also be making you and your family sick. Here are some simple changes that you can make, to benefit your health.

Pets

Getty – pets
Cats are the most common animal to cause allergy in humans.
We are a nation of pet lovers, and we keep around seven million cats and six million dogs.
Pets can improve our emotional wellbeing – but they can also make us feel unwell.
'Pets can exacerbate allergy symptoms because they have allergens in their urine, saliva and skin dander,' says Lindsey McManus of Allergy UK.
Cats are by far the commonest animals to cause allergy in humans, but any animal can cause a problem.
Pets can also carry salmonella, which can lead to diarrhoea and vomiting.
Cats can carry a parasite leading to toxoplasmosis in their faeces. This can be dangerous to children and can cause pregnant women to miscarry.

The solution

'Vacuum regularly, with a machine that contains a high-efficiency particulate air (HEPA) filter. This extracts even the smallest allergens from the air.
'Wash down surfaces regularly and damp dust,' says Lindsey McManus.
Discourage your pet from licking your face, and make sure that everyone in the family washes their hands after touching a pet.

Double glazing

Getty – double glazing
Double glazing is more energy efficient.
Double-glazed windows are now common because they're energy efficient and help to keep out the chill.
Unfortunately, they form such a good seal against the wind and weather – they also dramatically cut down ventilation.
'In the past, homes were draughty. This had the one advantage of reducing the amount of house dust mites, which are a major cause of allergy' explains Dr Adrian Morris, consultant allergist at the Surrey Allergy Clinic.
'House dust mites thrive in warm damp houses that have low levels of circulating air,' he says.
Condensation can also quickly build up due to moisture created by cooking, breathing and showering. Dampness causes mould, which can make asthma symptoms worse.

The solution

'Leave your windows ajar when you're in the house to keep your home well ventilated,' says Lindsey McManus.
'Invest in an extractor fan in the kitchen to remove steam and cooking smells. When you have a shower, make sure that you close the door – so the steam can't escape to the rest of the house. Open the bathroom window afterwards,' says Lindsey McManus.

Central heating

Getty – central heating
Try and keep your heating turned down as low as possible.
Homes today are normally fitted with central heating, which makes life comfortable for human occupants – as well as the house dust mite.
'In the winter months, centrally heated homes become ideal breeding grounds for the house dust mite,' says Dr Morris.
Carbon monoxide poisoning can be caused by faulty or poorly maintained gas boilers.

The solution?

Keep your central heating turned down as low as is comfortable, with a jumper on.
Keep windows open for ventilation.
Gas boilers should always be checked regularly by an expert to make sure that they're not leaking poisonous carbon monoxide into the home. This deadly gas can kill in extreme cases.

Kitchen chemicals

Fridge facts

A fridge must be used effectively, or it can even cause illness.
  • Keep it at the right temperature (between 0°C and 5°C).
  • Keep the fridge door closed as much as possible.
  • Wait for food to cool down before you put it in the fridge.
Sparkling kitchens look great. But household cleaning products can cause health problems and even in rare cases, chemical sensitivity syndrome.
Bleach is widely used to decontaminate surfaces and bathrooms. But it can release irritant vapours that can exacerbate asthma symptoms.
Many aerosol cleaning products contain volatile organic compounds (VOCs) that are used as propellants. These VOCs can cause headaches, drowsiness and general feelings of being unwell.

The solution

There are lots of natural products that can keep your home clean and smelling fresh.
Lindsey McManus advises using bicarbonate of soda as an abrasive cleaner.
'It also makes a great natural air freshener, mixed with water and a few drops of essential oil. Put it in a plant sprayer and spray it round the room,' she says.
Vinegar can also be used to clean windows and surfaces – and lemon juice can remove stains from work tops.

Feather duvets

Freezing food safely

  • Freeze it before the 'use by' date.
  • Follow any freezing or thawing instructions on the label.
  • Thaw it in the fridge, so it doesn't get too warm. Or, if you intend to cook it, as soon as it's defrosted, you could defrost it in a microwave.
  • Try to use it within one to two days after it's been defrosted – it will go off in the same way as if it were fresh.
Lots of people believe that they're allergic to feathers in pillows and bedding. But they may not be blaming the true culprit.
'True feather allergy is rare,' says Dr Harry Morrow Brown, a specialist in allergy and respiratory medicine at the consulting rooms at Highfield House, Derby.
'In most cases, the house dust mites on the feathers cause the symptoms,' he says.

The solution

The usual advice is to swap your feather bedding for non-feather alternatives.
However, a recent study compared different types of bedding, including feather foam and synthetic fibre, and found that house dust mites caused the least problem in feathers.
'We now suggest you use a high quality cotton pillow case, with a dense weave – so that allergens can't come through,' says Dr Brown.

Baby bottles

Getty – bottle
Many hard plastic baby bottles contain the chemical BPA.
There's been some concern that many hard plastic baby bottles contain the chemical Bisphenol A (BPA), which has been linked to an increased risk of breast and prostate cancer.
BPA is also found in a wide range of other plastic products, including lap top computers and tableware.
The Food Standards Agency in the UK has said that 'it's possible' that BPA may affect the hormone system in people's bodies. But there's not evidence that it causes harm in people.

The solution

If you're worried, switch to plastic bottles that don't contain BPA, or glass ones.
Don't fill up your baby's bottle with boiling water, since there's evidence that this makes it more likely the BPA will leach out of the plastic and into the fluid.
Discard old or worn bottles that are more likely to leach the BPA.
A good rule of thumb is not to keep a bottle longer than six months.

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