Disease Treatment and Continuing Symptoms by Mary Anderies
26/03/2007 - Ongoing digestive symptoms and other systemic problems
for individuals with Celiac Disease who are on a gluten free diet are
fairly common. While Celiac Disease itself is becoming more widely
recognized, its effects on multiple parts of the body and its ongoing
symptoms remain more obscure. While this article is not meant to provide
medical advice, it is intended to provide a summary of possible causes
that you and your health care provider may want to explore further.
Disease Follow Up Treatment
diagnosis of Celiac Disease is made, additional follow up tests are recommended
immediately after diagnosis and on an ongoing basis. These include:
- Blood work for vitamin and
- Thyroid Screen (note: Patients
on thyroid replacement and other medications may need frequent
- Monitoring for dosage adjustment
as their absorption improves.)
- Bone density scan
- Liver enzymes
Stanford University School of Medicine’s Celiac Management Clinic is noting
continued absorption problems with many individuals who are on a gluten
free diet. A 72 hour quantitative fecal fat test and a 25-gram xylose
sugar absorption test can help diagnose continued absorption problems.
progress on the gluten-free diet may be monitored by re-testing whichever
diagnostic blood test was initially highest, at an interval of 6 - 12
months. Children are likely to heal within a few months; adults may take a
few years, and some may never totally heal.
Calcium and Iron status will improve in most individuals even without
supplements once the intestine heals. Several doctors recommend NOT
prescribing drugs such as Fosamax and Evista until after the intestine
heals and more calcium is being absorbed from the diet.
Disease and Ongoing Symptoms After a Gluten-Free Diet
individuals will experience a significant decrease of symptoms within a
few weeks or months of starting a gluten free diet. However, some
individuals may continue to experience significant digestive problems or
may have a relapse of symptoms. Some possible explanations are summarized
any possible sources of gluten exposure. Binders in medication, cross
contamination, misunderstanding of the strictness required of the diet,
etc. should be explored. Repeat blood tests might give an indication of
continued gluten exposure; however these may not be sensitive enough to
note low level exposure.
during the healing phase of celiac disease, intolerance to lactose, a
protein found in dairy products, may be seen. Enzymes needed to digest
lactose are manufactured by the intestinal villi, which have been damaged
by exposure to gluten. Often once the villi have regrown, symptoms of
lactose intolerance will subside. Testing includes Lactose H2 breath
testing. Suggested treatment includes using an over-the-counter lactose
enzyme when ingesting dairy products. Re-colonizing the small intestine
with beneficial bacteria (see probiotics, below) is also recommended.
A study by
Villanacci, et. al, published 8/28/2006 in the American Journal of
Gastroenterology noted that 44% of individuals diagnosed with celiac
disease tested positive for Helicobacter Pylori at the time of, or within
1 year of their celiac disease diagnosis.
Bowel Bacterial Overgrowth
In a report
published in the American Journal of Gastroenterology, Vol. 98, No. 4,
2003 of 15 persons with continuing symptoms, 10 showed evidence of
overgrowth of bacteria within the small bowel. Testing included Lactulose
H2 breath testing. Suggested treatment includes the non-systemic,
prescription antibiotic, Rifaximin (800 mg. per day for one week). Note
that the antibiotic used is called Rifaximin in England and Xifaxam in the
U.S. Digestive function should also be evaluated as the underlying cause
individuals report continuing symptoms due to overgrowth of yeast. Testing
includes blood antibody testing for Candida. Suggested treatment includes
½ tsp Nystatin powder (mix with water), twice a day and 200 mg
Ketoconizole once per day for 2-3 months. Monthly liver function testing
during treatment is recommended. Nystatin powder may be ordered, by
prescription, through pharmacies which offer custom compounding of
medications. Digestive function should also be evaluated as the underlying
cause of yeast overgrowth. Dietary changes may also be considered.
IgG food sensitivities may be seen. An IgG sensitivity is different from
the IgE allergies most allergy doctors check for. Common food
sensitivities include dairy casein, corn, soy and eggs. Treatment includes
avoiding the food, and food rotation. There are some reports of a
reduction of food sensitivities when digestive function improves.
problems with digestive function may be found. A complete evaluation
should be done. One source for a comprehensive stool analysis may be
obtained, by mail and by prescription.
intestinal motility may contribute to continuing diarrhea. Try reducing
motility by using a fiber supplement like Benefiber or Citracel.
Particularly in individuals who have had their gall bladder removed,
consider Cholestid, a prescription drug used for lowering cholesterol,
which may also slow motility. It acts by binding to irritating bile salts.
acid (hypochlohydria) may interfere with the effectiveness of one’s own
digestive enzymes and may create an environment that encourages yeast or
bacterial overgrowth. Additional information may be found in the book
“Why Stomach Acid is Good for You” by Wright & Lenard. Testing may
be done using the Heidleberg Capsule or Gastrocap tests. Supplemental
Betaine HCl, bitters, digestive enzymes and probiotics, available at a
health food store, may be helpful.
are very helpful for regaining the balance of the intestinal flora. Use
ones that have multiple kinds of bacteria. The ones found in the
refrigerated section of health food stores will have the highest level of
bacteria. Kefir, raw kimchee and raw sauerkraut, also found in the
refrigerated section, have high levels of active cultures.
enzymes assist with more complete digestion, discouraging unhealthy
bacterial growth. Recommendations have been made for the vegetable based
enzymes Which may be ordered through the internet or found in health food
stores. Animal derived enzymes are available by prescription. Experiment
to see what works best. To avoid heartburn, start by sprinkling ½ of a
capsule on food & increase as needed and tolerated. Be sure to
carefully check the Gluten-Free status of all enzymes. It is common for
the Maltase to be made from barley.
individuals do not digest carbohydrates and sugars well. The undigested
carbohydrates encourage the growth of harmful yeasts and bacteria. More
information on a diet low in carbohydrates may be found in the book
“Breaking the Vicious Cycle” by Gottschall. She recommends eliminating
all complex carbohydrates to kill off the bad bacteria.
and other bacterial problems
parasites and other bacterial problems, including Giardia lamblia and
Ascaris lumbricoides. Just because an individual has celiac disease,
doesn't mean they can't have the bugs that a normal person with diarrhea
1/3 of the people diagnosed with celiac disease as adults will also have
another autoimmune disease. Many report a significant improvement in their
other autoimmune disease after beginning a gluten free diet. However, some
individuals with celiac disease may develop other autoimmune diseases even
after beginning a gluten free diet. Watch for Type 1 diabetes, liver,
thyroid, pancreas and adrenal diseases, peripheral and central nervous
system damage, connective tissue and other rheumatoid inflammations.
Anderies also serves as a member of the Denver Metro Chapter of CSA/USA
Medical Education Committee