Heartburn and Celiac Disease: Gluten Sensitivity as a Reversible Cause of Gastroesophageal Reflux

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One of the symptoms many people experience frequently and most people have had sometime in their adult life is heartburn. The medical term for this is pyrosis, from the Greek word pyro meaning fire or heat. Heartburn is the classic symptom of gastroesophageal reflux (GER) or reflux. Most people have heard of these terms now because you can't sit through an hour of television these days without seeing at least one commercial if not several advertising antacids like tums or acid blockers like Pepcid AC and Nexium. Most people are not aware that heartburn is a common symptom of gluten intolerance or sensitivity.

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How is Heartburn and Celiac Disease: Gluten Sensitivity as a Reversible Cause of Gastroesophageal Reflux

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Celiac disease, which is a severe intolerance to gluten (the major storage protein in wheat and similar proteins in barley and rye resulting in intestinal damage) is estimated to affect 1 in 133 people in the U.S. and approximately 1/100 worldwide. Most of these people are undiagnosed. Many are being treated for reflux, irritable bowel syndrome, gas-bloat dyspepsia, lactose intolerance, or just suffering ill health unaware that a gluten free diet (GFD) might relieve their symptoms if not improve them significantly.

Dyspepsia is a medical term for stomach upset, indigestion or gas-bloat abdominal discomfort. This commonly occurs in celiac disease. Stomach contractions have been shown to be impaired in celiac disease contributing to the bloating sensation. This is confirmed by diagnostic studies revealing poor stomach emptying. Delayed stomach emptying is frequently accompanied by low pressures in the lower esophageal sphincter (LES) of the esophagus or swallowing tube. The LES is supposed to be a barrier to regurgitation of stomach contents up into the esophagus. When stomach juice that is acidic refluxes into the esophagus a burning pain is typically felt in the chest that is described by most people as heartburn.

When acid frequently regurgitates up into the esophagus a burn of the lining occurs that is termed esophagitis or reflux esophagitis and defines gastroesophageal reflux disease (GERD). Celiac disease patients have been shown to have a high prevalence of GERD and reflux esophagitis. Treatment with a gluten free diet has been shown to decrease the rate of relapse of GERD symptoms. In clinical practice, many of us have observed that a gluten free diet results in marked improvement of heartburn symptoms in not just celiac disease but in many people.

As a practicing gastroenterologist, (www.thefooddoc.com) I have had patients referred to me for reflux symptoms including several who were being considered for possible surgery for GERD. Upon discovery of celiac disease or non-celiac gluten sensitivity and institution of GFD they have had improvement or resolution of symptoms. Personally, I experienced frequent enough heartburn that I was taking a daily acid blocker. When I discovered that though I had symptoms of gluten sensitivity and was DQ2 positive I had negative blood tests but elevated fecal gliadin IgA and tissue transglutaminase IgA antibodies, I initiated a GFD. My heartburn went away and I stopped taking a daily acid blocker. Now I only have heartburn rarely, usually with obvious dietary indiscretions like too much coffee, chocolate or wine.

My friend and colleague, Dr. Rodney Ford, who practices pediatric gastroenterology in New Zealand, has communicated to me his similar experience with children. Since expanding gluten free diet to those children he suspects of gluten sensitivity, not just those in whom celiac disease is confirmed by traditional or classic strict diagnostic criteria, he has noted a marked decrease in the number of children with GER. He states it has been many years since he has had to refer a child for surgery for reflux.

There have been concerns about clinical significance of known acid suppressive therapy impairment of digestion though so far the worries about the increased risk for cancer seen in lab rats have been unfounded. Recently, an increase risk of community-acquired pneumonia attributed to loss of acid reduction of bacteria in the stomach was found in patients with chronic lung disease or with other risk factors. There also is the on going debate about the high costs of the newer, more effective acid blocking drugs as well as their potential side effects. Some also raise concerns of an increased risk of food intolerance or allergy while on acid suppression. These issues and the risks of undiagnosed celiac disease not withstanding should give one pause to the idea of chronic acid suppressive therapy without investigating the possibility of undiagnosed celiac or gluten sensitivity with a trial of GFD.

Copyright 2006 The Food Doc, LLC. http://www.thefooddoc.com

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Brain And Neurological Problems Affect Almost Half Of Celiacs Even With A Gluten Free Diet

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Pediatric Physicians - Brain And Neurological Problems Affect Almost Half Of Celiacs Even With A Gluten Free Diet

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There is reasonable evidence of neurological problems in Celiac disease (CD) even those well treated on a gluten-free diet should undergo periodic neurological screening. Peripheral neuropathy is found in almost half of people with CD. Previously, neurological complications in Celiac disease were reported to be as high as 36% or more than a third. Some unexplained neurological problems are present but not recognized by the patient or their doctor in many patients and some have several problems. Unfortunately, since brain imaging is not routinely done or recommended in those who are newly diagnosed we don't really know how high these numbers may be really be. More staggering is the fact that we are still learning about people who fail to meet diagnostic criteria for Celiac disease but are being found to have gluten related neurological problems that respond to a gluten-free diet.

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There are many neurological problems that in undiagnosed and untreated Celiac disease but include neuropathy, balance problems (ataxia), seizures, MS-like symptoms, headaches, memory impairment, depression and anxiety, inattention (ADD/ADHD), schizophrenia, dementia, muscle weakness, childhood developmental delay, autism (Asperger's). The sad truth is that many patients have delays in diagnosis that result in delayed treatment and poor response even while adopting a strict gluten free diet. The average delay of diagnosis in adults is between eleven and thirteen years. Dr. Hadjivassiliou, a neurologist in England who is considered the world's expert in gluten related neurological problems has communicated to me by e-mail and written that responses to a gluten-free diet may take five years and if the neurological condition has been longstanding complete recovery is not likely.

The symptoms of neuropathy are paresthesia (numbness) or dysthesia (burning, tingling, heaviness, "pins and needles" sensation"). Many of my patients also describe hypersensitivity of their skin such that they do not like air blowing on them or their children or spouses against their skin. Some admit to "bug crawling" sensation on their skin, something called vermiculation in medical terms but rarely asked about or given much thought by most doctors. Odd muscle movements under the skin that some call a "bag of worms" medically known as fasiculations are also very common but dismissed by many doctors. My wife, a physician with Celiac disease, actually had these occur while undergoing an EMG (electromyleograph, recording of muscle activity by placing needle electrode into the muscle) exam by an older neurologist. Despite observing these occurring visually and the monitor showing "static like noise" the neurologist dismissed them as "normal".

Many patients with Celiac disease also have what the radiologists and neurologists call "UBO's" on MRI exams of the brain. These unidentified bright objects (think UFO) are white spots that show up on images of the brain. When found in certain locations of the brain they are highly suggestive of multiple sclerosis (multiple scarring spots in the brain). However, though many people with CD have MS like symptoms and these symptoms often respond to a gluten free diet when started early enough, the UBO's seen on MRI of the brain are typically not in the classic areas of MS. Instead it is common to find them in areas of the brain associated with migraines or balance difficulty (ataxia).

Some are seen in children associated with strange seizure problems even without obvious intestinal symptoms. A classic specific syndrome is very well recognized associated with epilepsy in both children and adults who have calcifications in their brain that can be detected by CT scan or MRI. Epilepsy is well documented but the studies are confusing enough that there is not a good consensus regarding the risk and recommended screening of all children with epilepsy.

Personally and professionally I have observed all of the neurological complications of Celiac disease and most of them I have also noted in patients in whom I have not been able to confirm CD but who have what I believe are objective signs and/or genetic risk for gluten sensitivity. I have patients with MS-like symptoms, chronic unexplained neuropathy, headaches, attention difficulties, autistic behaviors and developmental delays who have responded to gluten-free diet but if they had listened to doctors who maintained such a "restrictive, expensive, hard to follow" diet should only be "imposed" on those with a established diagnosis of Celiac disease.

If you have neurological problems get testing for Celiac disease before starting a gluten-free diet. If you test negative for CD, make sure they test you for the complete HLA DQ genetics that includes the high-risk white blood cell patterns DQ2 and DQ8 for Celiac disease AND get blood tests that include IgG and IgA gliadin antibodies. If your blood tests, including gliadin IgA and IgG antibodies, are negative or normal then consider stool testing for gliadin antibodies in the stool (, http://www.enterolab.com).

The evidence continues to accumulate, though often ignored or missed, that gluten is toxic to some people's brains, even if they do not have CD. If you do have Celiac disease it is likely you already have neurological problems and may be at risk despite being on a gluten-free diet. Borrowing from the old advertisement against drug abuse "this is your brain on drugs" maybe we should be getting the word out "this is your brain on gluten". Despite your test results, consider a trial of gluten-free diet after you have your testing done if you have unexplained or unresponsive neurological problems. You owe to your brain. Like my seven-year-old son said to one of our friends, "maybe you should lay off the gluten".

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