Coeliac disease is an organic disease, which affects the small bowel mucosa causing disturbance of absorptive functional capacity of small intestine. The disease appears in predisposed individuals as a result of dietary exposure to gluten. The classical nature of coeliac disease is characterized by mucosa inflammation, villous atrophy, and crypt hyperplasia. Clinical and histological finding show an improvement coupled with withdrawal of gluten from the diet .
Coeliac disease is also known as Coeliacsprue, gluten-sensitive enteropathy or non tropicalsprue . The disease develops as a response to the dietary ingestion of glutens (prolamins and glutenins) of wheat and similar proteins in barley, rye and oats resulting in activation of both cell-mediated (T-cell) and humoral (B-cell) immune response in genetically susceptible persons .
Genetic predisposition is suggested by a high concordance amongst monozygotic twins approaching 70%, and in association with certain type II Human Leukocyte Antigens (HLA). Between 75% to 95% of HLA DQ2 is found in coeliac disease patients, whilst, most of the remaining patients have HLA DQ that are located in number six chromosome .
Environmental factors may also play a role in expression of coeliac disease whereas; some other factors may play a role in precipitating the symptoms. These include viral infection, high dose of gluten or early gluten challenge and pregnancy .
Coeliac patients are also specifically characterized by the presence of auto-antibodies to a connective tissue element surrounding smooth muscle called endomysium, which is highly specific for coeliac disease and known as endomyseal antibodies. Furthermore, an enzyme called tissue transglutaminase (tTG) may play a role in the pathogenesis of coeliac disease by modifying gluten peptides .
Coeliac disease appears actually in different clinical pictures and presentations.
Classical coeliac disease is gluten induced villous atrophy and presents in classical picture of intestinal malabsorption. Atypical coeliac disease might present in other different pictures such as decreased calcium levels, iron deficiency, osteoporosis, short stature, miscarriage and infertility. Silent coeliac disease might be discovered by serological screening or endoscope done to investigate other causes that are not related to the disease itself. Another form of the disease is known as latent coeliac disease characterized with delayed appearance of signs and symptoms of the disease, and it shows improvement on a gluten-free diet and appearance of normal mucosal histology .
Prevalence of coeliac disease is difficult to be estimated because of the different forms of clinical picture and variety in presentation of the disease itself, especially in patients who have mild form of the disease or those who have no apparent signs or symptoms. The highest prevalence of disease was estimated among Celtic populations and It was 1:300 to1:80 . A high prevalence of coeliac disease was estimated in European populations and the incidence was slightly high amongst girls (57%). Sub clinical or silent coeliac disease was most abundant . In the general population of developed societies it is estimated that prevalence of coeliac disease ranged mostly from 0.5% to 1%. Whilst, in the Sahara population who are African descendants of Arab-Berber and live in great African Desert “Sahara” the highest records of coeliac disease were reported and it appeared to be 5.6%, which was almost five to ten times more frequent than that in Europe .
In the Gaza strip, the already diagnosed cases of coeliac disease have been estimated at 237 patients i.e. 0 02% of the total population in the Gaza strip .
The diagnosis of coeliac disease is classically based on clinical suspicion or atypical presentations. Compatible further many serologic markers and duodenal biopsy is the most reliable diagnostic procedure in coeliac disease.
The major complications of coeliac disease include intestinal T-cell lymphomas and extra intestinal malignancies like Non Hodgkin lymphoma and esophageal cancer. Poor dietary compliance on the long run is associated with long term complications such as chronic malnutrition, decreased blood calcium level, neurological complications, miscarriage, congenital malformations, and low birth weight of babies. Those complications are responsible for the bad prognosis of patients. It is actually improved by taking gluten free diet .
Changing lifelong eating habits and adapting new gluten free lifestyle can be a big challenge for most people with coeliac disease because gluten free diet is expensive and does not taste as good as regular foods. Hectic nutritional lifestyles may resXult in insidious intake of gluten which might be included or hidden in foods or medications that possibly contain wheat or other grains. Good dietary compliance decreases the risk for future complications and improves life of coeliac patients .